Transitions in Palliative and End-of-Life Care

Abstract

In palliative and end-of-life care, people with serious illness and their families experience a number of transitions—in functional status, physical location, cognitive abilities, and goals of care. This chapter focuses on care transitions in location and treatment preferences and discusses some pitfalls of transitions, along with telemedicine as a palliative care tool to reduce the burden of transitions. Medication reconciliation between sites of care and interprofessional coordination of care among various clinicians and teams are important elements of safe, effective care transitions. Respecting a patient’s autonomy while optimizing safety can be a challenge, and care decisions in times of transition should be person centered, holistic, and compassionate.