Integrating Hospice and Palliative Medicine: A Comprehensive Analysis of UC Davis Health’s New Division

2025-12-26 Research Reports 0

Abstract

The profound demographic shift towards an older global population necessitates a fundamental re-evaluation of healthcare delivery models, particularly for individuals navigating complex, multi-morbid conditions and the final stages of life. This comprehensive report meticulously examines the pioneering integration of hospice and palliative medicine into a unified Division of Geriatrics, Hospice, and Palliative Medicine at UC Davis Health. The initiative represents a significant paradigm shift, strategically positioned to enhance interdisciplinary care, address the critical shortage of geriatricians, and champion the principles of healthy aging. Beyond the specific institutional context, this report delves into the broader philosophical underpinnings of palliative and hospice care, explores sophisticated service delivery models, scrutinizes existing and emerging funding mechanisms, navigates the intricate ethical considerations inherent in end-of-life planning, and profoundly discusses the overarching impact of such integrated approaches on patient dignity, autonomy, and comprehensive family support during periods of serious illness and bereavement. This detailed analysis aims to illuminate the multifaceted benefits and operational complexities of integrated geriatric and palliative care, offering insights potentially applicable to healthcare systems globally.

1. Introduction

Societies worldwide are undergoing an unprecedented demographic transformation, characterized by a rapidly aging population. In the United States, projections indicate that by 2030, one in five Americans will be 65 years or older, with a significant increase in the ‘oldest old’ (those aged 85 and above) (U.S. Census Bureau, 2020). This demographic shift brings with it a corresponding rise in the prevalence of chronic diseases, multimorbidity, functional decline, and cognitive impairment among older adults, presenting formidable challenges to traditional healthcare systems (National Institute on Aging, 2020). The complex interplay of these health conditions often necessitates specialized care that addresses not only physical ailments but also psycho-social, spiritual, and functional needs.

In direct response to these evolving challenges, UC Davis Health has taken a forward-thinking step by establishing a new Division of Geriatrics, Hospice, and Palliative Medicine. This strategic integration is designed to provide comprehensive, patient-centered care for this vulnerable demographic, moving beyond fragmented service delivery towards a cohesive model. The division aims to synergistically combine the expertise of specialized geriatrics professionals—who possess deep knowledge of age-related physiological changes, geriatric syndromes, and complex medication management—with the compassionate, holistic approach of hospice and palliative care specialists. This collaborative effort is intended to ensure that older adults receive a continuum of care that spans from proactive healthy aging strategies through advanced illness management and dignified end-of-life support (health.ucdavis.edu). The initiative at UC Davis Health serves as a compelling case study for how academic medical centers can innovate to meet the demands of an aging society, fostering an environment where quality of life and patient values are central to care planning.

2. Formation and Objectives of the New Division

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2.1. Rationale for Integration

The decision by UC Davis Health to merge geriatrics, hospice, and palliative medicine into a single, cohesive division is rooted in a profound understanding of the specific healthcare landscape facing older adults. Traditional healthcare models frequently segregate specialties, often leading to disjointed care, conflicting treatment plans, and an undue burden on patients and their families to navigate complex systems. Older adults, however, rarely present with a single, isolated condition; instead, they often contend with multiple chronic conditions (multimorbidity), geriatric syndromes such as frailty, falls, cognitive impairment, and polypharmacy (the use of multiple medications). These challenges are compounded by a lack of coordination across various care providers and settings (Huston, 2013).

By unifying these three highly specialized yet inherently interconnected fields, the division aims to create a powerful synergy. Geriatricians possess expertise in optimizing health and function in older adults, addressing age-related physiological changes, and managing complex medication regimens. Palliative care specialists focus on relieving suffering and improving quality of life for patients with serious illnesses, regardless of prognosis, through expert symptom management and psychosocial support. Hospice care provides comprehensive comfort care for individuals in the final stages of a terminal illness, focusing on dignity and quality of life when curative treatments are no longer desired or effective. The convergence of these disciplines within one division offers several compelling advantages:

  • Streamlined Services: Integration allows for a more seamless transition of care as patients’ needs evolve, from preventative geriatrics to complex illness management, and eventually to end-of-life care, if required. This reduces administrative burden and improves patient experience.
  • Reduced Unnecessary Hospitalizations: Proactive geriatric assessment and palliative symptom management can often prevent acute exacerbations of chronic conditions, leading to fewer emergency department visits and hospital admissions. Comprehensive care planning, including advance care planning, also helps patients receive care aligned with their wishes, potentially avoiding aggressive, unwanted interventions.
  • Cohesive, Interdisciplinary Care: The unified structure inherently promotes collaboration among a diverse team of healthcare professionals. This ensures a holistic approach to patient care, addressing physical, psychological, social, and spiritual dimensions of well-being. For instance, a geriatrician might identify the onset of frailty, a palliative care specialist might manage pain and nausea from advanced disease, and a hospice team might provide comfort and family support during the last months of life, all under a coordinated framework.
  • Addressing the Geriatrician Shortage: The integration also serves as a strategic response to the severe national shortage of geriatricians. By fostering fellowship programs that include hospice and palliative medicine, the division is not only training a new generation of specialists but also equipping them with a broader skill set that is highly relevant to the complex needs of older adults. This multidisciplinary training enhances their value and impact across the healthcare continuum.

Ultimately, the rationale for this integration is to provide truly patient-centered care, anticipating and responding to the multifaceted needs of older adults with serious illnesses, thereby enhancing their quality of life and supporting their families (health.ucdavis.edu).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2.2. Leadership and Structure

The success of such an ambitious integration hinges significantly on visionary leadership and a well-defined organizational structure. UC Davis Health has appointed Dr. Rebecca Boxer, a highly respected geriatrician and accomplished researcher, as the chief of the new Division of Geriatrics, Hospice, and Palliative Medicine. Dr. Boxer’s background uniquely positions her to lead this integrated division, bringing expertise in the complex medical needs of older adults combined with an understanding of the holistic principles of palliative care. Her leadership is crucial in shaping the division’s clinical services, educational programs, and research initiatives.

Under Dr. Boxer’s guidance, the division is structured to encompass a broad spectrum of programs and services aimed at comprehensive older adult care:

  • The Healthy Aging Clinic: This flagship program exemplifies the multispecialty team approach central to the division’s philosophy. It offers comprehensive geriatric assessments, which go beyond routine medical check-ups to evaluate physical function, cognitive status, nutritional health, social support, and medication management. The clinic’s team typically includes geriatricians, advanced practice nurses, social workers, pharmacists, and rehabilitation therapists who collaborate to develop personalized care plans focusing on prevention, maintenance of independence, and management of chronic conditions. The goal is to empower older adults to age healthily and maintain their highest possible quality of life (health.ucdavis.edu).
  • Inpatient Geriatric and Palliative Consultations: The division provides specialized consultation services within the hospital setting. Geriatricians can assist with complex cases involving delirium, falls, polypharmacy, and functional decline, while palliative care teams offer expert symptom management, goals-of-care discussions, and emotional support to patients with serious illnesses and their families. This ensures that specialized care is available at critical junctures of illness.
  • Hospice Services: The division oversees or collaborates closely with existing hospice services, ensuring that patients who meet eligibility criteria for hospice receive compassionate end-of-life care focused on comfort, dignity, and family support.
  • Outpatient Palliative Care Clinic: For patients with serious chronic illnesses who are not yet eligible for hospice or are still pursuing curative treatments, the outpatient palliative care clinic offers ongoing symptom management, emotional support, and advance care planning guidance, helping to improve their daily quality of life.
  • Fellowship Programs: A critical component of the division’s long-term vision is workforce development. The division offers robust fellowship programs in geriatrics, hospice, and palliative care. These programs are designed to train the next generation of leaders in these fields, equipping them with the specialized knowledge and interdisciplinary skills required to provide comprehensive care to older adults and those with serious illnesses. By integrating the training, fellows gain a holistic perspective, understanding the continuum of care from disease prevention and healthy aging to end-of-life management. This also helps to mitigate the projected shortage of specialists in these vital areas (American Geriatrics Society, 2021).
  • Research and Education: Beyond clinical care, the division is committed to advancing the understanding of aging and serious illness through research. This includes studies on geriatric syndromes, optimal models of integrated care, symptom management, and effective communication strategies. Educational initiatives extend beyond fellowship programs to include training for medical students, residents, and other healthcare professionals, disseminating best practices and fostering a culture of compassionate, patient-centered care throughout the health system.

The organizational structure within the Department of Internal Medicine allows for strong collaboration with other specialties, enhancing the division’s ability to provide comprehensive, integrated care across the health system.

3. Philosophical Foundations of Hospice and Palliative Medicine

Hospice and palliative medicine, while distinct in their application, are fundamentally united by a common philosophical core: the holistic care of patients with serious illnesses, prioritizing quality of life, relief of suffering, and compassionate support for patients and their families. Understanding these foundational principles is crucial to appreciating the value of their integration with geriatrics.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.1. Defining Palliative Care

The World Health Organization (WHO) defines palliative care as ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’ (World Health Organization, 2021). Key tenets of palliative care include:

  • Holistic Focus: Palliative care addresses the totality of a person’s experience, encompassing physical symptoms (pain, nausea, fatigue), psychological distress (anxiety, depression), social challenges (isolation, caregiver burden), and spiritual concerns (meaning, hope, reconciliation).
  • Quality of Life: The primary goal is to enhance the patient’s and family’s quality of life. This involves aggressive symptom management, communication, and decision support.
  • Early Integration: Crucially, palliative care can and should be provided at any stage of a serious illness, from diagnosis onwards, alongside curative or life-prolonging treatments. It is not exclusively for the end of life.
  • Interdisciplinary Team Approach: Effective palliative care relies on a team of professionals working collaboratively to meet complex needs.
  • Family-Centered Care: Family caregivers are integral to the patient’s well-being and receive support and counseling.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.2. Defining Hospice Care

Hospice care is a specialized form of palliative care specifically designed for patients in the final stages of a terminal illness, typically with a prognosis of six months or less if the disease runs its natural course, as certified by a physician. The core philosophy of hospice is to affirm life and regard dying as a natural process, neither hastening nor postponing death (National Hospice and Palliative Care Organization, 2023). Key aspects include:

  • Comfort-Focused: Hospice shifts the focus from curative treatments to symptom management and comfort.
  • Terminal Prognosis: Eligibility requires a physician’s certification of a limited life expectancy.
  • Home-Based Care: While hospice can be provided in various settings (inpatient units, nursing homes), the majority of hospice care is delivered in the patient’s home, allowing them to remain in a familiar and comforting environment.
  • Interdisciplinary Team: Similar to palliative care, hospice utilizes a comprehensive team, including nurses, physicians, social workers, chaplains, home health aides, and volunteers.
  • Bereavement Support: Hospice provides grief and bereavement support for families extending up to a year after the patient’s death.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.3. Overlapping Principles and Distinctions

Both hospice and palliative care are rooted in principles of compassion, patient autonomy, and interdisciplinary collaboration. They both aim to relieve suffering and improve quality of life. The critical distinction lies primarily in timing and intent: palliative care can be integrated at any point in a serious illness, often alongside aggressive curative treatments, whereas hospice care is specifically for those with a terminal prognosis who have chosen to forgo curative treatments in favor of comfort-focused care (Centers for Medicare & Medicaid Services, 2023). Palliative care can be seen as a broad umbrella, under which hospice care is a more specific subset for end-of-life care.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3.4. Ethical Underpinnings

At the heart of both disciplines are profound ethical commitments. Respect for autonomy ensures that patients have the right to make informed decisions about their care, aligned with their values and preferences, even if those decisions involve foregoing life-prolonging treatments. The principle of beneficence compels providers to act in the patient’s best interest, promoting well-being and comfort. Non-maleficence demands the avoidance of harm, particularly through aggressive treatments that may cause more suffering than benefit. Finally, justice calls for equitable access to high-quality palliative and hospice care for all individuals, regardless of their socioeconomic status, race, or geographic location. These ethical foundations guide clinical practice, communication strategies, and the overall approach to care for vulnerable populations (Quill & Abernethy, 2013).

4. Service Delivery Models

Effective and integrated hospice and palliative care relies on sophisticated service delivery models that ensure continuity, coordination, and comprehensiveness. The integration within UC Davis Health seeks to optimize these models, ensuring that care is tailored to patient needs across various settings and disease trajectories.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.1. Interdisciplinary Team-Based Care – A Deep Dive

The cornerstone of effective hospice and palliative care is the interdisciplinary team (IDT). This collaborative approach recognizes that patients with serious illnesses have complex, multidimensional needs that transcend the scope of any single medical specialty. The IDT comprises a diverse group of professionals, each contributing their unique expertise, working in concert to provide holistic assessment and management of the patient’s physical, emotional, social, and spiritual needs. The core members and their roles typically include:

  • Physician (Geriatrician, Palliative Care Physician): Provides medical oversight, diagnoses, prognostication, complex symptom management (e.g., pain, dyspnea, nausea), goals-of-care discussions, and coordination with other medical specialists.
  • Registered Nurse (RN): Often the central point of contact, nurses provide direct patient care, administer medications, monitor symptoms, educate patients and families, and coordinate care plans. They are crucial in assessing physical symptoms and functional status.
  • Social Worker: Addresses psychosocial needs, assists with coping strategies, navigates community resources, facilitates family communication, helps with financial and legal planning (e.g., advance directives), and provides emotional support.
  • Chaplain/Spiritual Counselor: Offers spiritual assessment and support, helps patients and families explore existential questions, provides comfort and meaning-making opportunities, and connects with community spiritual resources consistent with the patient’s beliefs.
  • Pharmacist: Manages polypharmacy, optimizes medication regimens to control symptoms while minimizing side effects, and educates on drug interactions and proper use.
  • Certified Nursing Assistant (CNA)/Home Health Aide: Provides personal care, assistance with daily living activities (e.g., bathing, dressing), and respite for family caregivers, particularly in home-based hospice settings.
  • Bereavement Counselor: Offers grief support and counseling to families before and after the patient’s death.
  • Other Specialists (as needed): Physical therapists (for mobility and strength), occupational therapists (for daily living activities), nutritionists (for dietary support), child life specialists (for pediatric palliative care), and volunteers (for companionship and practical support).

Mechanism of Collaboration: The IDT meets regularly (e.g., weekly case conferences) to discuss patient progress, review care plans, identify emerging needs, and ensure alignment with patient goals. This structured communication facilitates shared decision-making, resolves potential conflicts, and ensures that all aspects of the patient’s well-being are addressed comprehensively. At UC Davis Health, the Palliative Care Services team exemplifies this model, working collaboratively with patients’ primary care providers and other specialists to develop individualized care plans that reflect the patient’s values and preferences (health.ucdavis.edu). This integrated approach prevents duplication of services, enhances efficiency, and most importantly, improves the quality and coordination of care.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4.2. Integration Across Care Settings

Providing continuous and coordinated care necessitates integrating hospice and palliative care services across the entire spectrum of healthcare settings. This adaptability ensures that patients receive appropriate care tailored to their current needs, regardless of their location or stage of illness.

  • Inpatient Settings:

    • Consultation Services: Palliative care teams provide consultation services to patients admitted to hospitals, offering expert symptom management, assisting with complex medical decision-making, and facilitating goals-of-care discussions with patients and families. These services are crucial in intensive care units, oncology wards, and medical-surgical units.
    • Dedicated Palliative Care Units/Beds: Some hospitals feature dedicated palliative care units or designated beds, offering specialized environments for symptom control, family support, and end-of-life care when home care is not feasible.
    • Geriatric Consultation: Geriatricians provide consultations for hospitalized older adults, focusing on delirium prevention, fall risk assessment, medication review, and discharge planning to prevent rehospitalizations.

  • Outpatient Settings:

    • Specialty Clinics: Outpatient palliative care clinics provide ongoing symptom management, emotional support, and advance care planning for patients with chronic or serious illnesses who are living in the community. These clinics can be co-located with oncology, cardiology, or neurology clinics for seamless referrals.
    • Healthy Aging Clinic: As part of the UC Davis Health division, the Healthy Aging Clinic serves as an outpatient hub for comprehensive geriatric assessments, preventative care, and management of age-related conditions, providing a crucial entry point for older adults into integrated care.
    • Virtual Care (Telehealth): The increasing adoption of telehealth allows for remote consultations, symptom monitoring, and support, improving access for patients in rural areas or those with mobility limitations, especially pertinent in geriatrics and palliative care.

  • Home-Based Care:

    • Hospice at Home: The most common model for hospice care, allowing patients to remain in the comfort and familiarity of their own homes, supported by regular visits from the hospice IDT. This model significantly enhances patient dignity and family well-being.
    • Palliative Home Care: For patients not yet eligible for hospice but requiring complex symptom management or support at home, palliative home care teams can provide in-home visits and remote monitoring, reducing hospital visits and improving quality of life.

  • Long-Term Care Facilities: Collaboration between the integrated division and nursing homes, assisted living facilities, and skilled nursing facilities ensures that residents receive appropriate geriatric and palliative interventions, reducing transfers to acute care hospitals and improving quality of life within these settings.

  • Continuity of Care: The ultimate goal is to ensure seamless transitions between these settings. This is facilitated by shared electronic health records, dedicated care navigators, and robust communication protocols between inpatient and outpatient teams. UC Davis Health’s integrated division aims to enhance this continuity, ensuring that patients receive appropriate, personalized care throughout their illness trajectory (health.ucdavis.edu). This continuous, coordinated approach prevents gaps in care, reduces patient and caregiver stress, and ultimately improves clinical outcomes and patient satisfaction.

5. Funding Mechanisms

The sustainability and accessibility of hospice and palliative care services are heavily dependent on robust and equitable funding mechanisms. In the United States, Medicare plays a significant role, but a patchwork of public and private funding sources, coupled with innovative models, is necessary to support these essential services.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.1. Medicare’s Hospice Benefit – Comprehensive Analysis

Medicare’s Hospice Benefit, established in 1982, is a pivotal funding mechanism for end-of-life care in the United States. It is designed to cover comprehensive services for eligible patients, emphasizing comfort and quality of life over curative treatments during the final stages of life. Understanding its structure is crucial:

  • Eligibility Criteria:

    • Part A Enrollment: Patients must be entitled to Medicare Part A (Hospital Insurance).
    • Terminal Illness: A physician (and a hospice medical director) must certify that the patient has a terminal illness with a prognosis of six months or less if the disease runs its natural course. This certification must be renewed for subsequent benefit periods.
    • Waiver of Curative Treatments: Patients must elect to receive hospice care and waive their right to Medicare payment for services related to their terminal illness that are curative in intent. They can still receive curative care for unrelated conditions.

  • Covered Services: The Medicare Hospice Benefit is comprehensive, covering virtually all care related to the terminal illness, often at little to no out-of-pocket cost to the patient. Covered services typically include:

    • Physician Services: Visits by hospice physicians and nurse practitioners.
    • Nursing Services: Skilled nursing care provided on an intermittent basis, including symptom management, wound care, and patient/family education.
    • Medical Equipment and Supplies: Durable medical equipment (e.g., hospital beds, wheelchairs, oxygen) and supplies (e.g., bandages, catheters) necessary for comfort and care.
    • Medications: Drugs for symptom control and pain relief related to the terminal illness.
    • Therapies: Physical, occupational, and speech therapy services if they are for symptom management or to maintain functional abilities.
    • Social Work Services: Counseling, resource navigation, and emotional support for patients and families.
    • Spiritual Counseling: Services provided by chaplains or spiritual counselors to address spiritual needs and concerns.
    • Home Health Aide and Homemaker Services: Assistance with personal care (bathing, dressing) and light household tasks, providing respite for family caregivers.
    • Respite Care: Short-term inpatient care (up to five days) to give family caregivers a break.
    • Bereavement Support: Counseling and support for family members for up to one year after the patient’s death.

  • Reimbursement Model: Medicare pays hospices a daily rate (per diem) for each day a beneficiary is enrolled, regardless of the level of service provided on a given day, with adjustments for different levels of care (routine home care, continuous home care, inpatient respite care, general inpatient care). This model incentivizes efficient care but can pose challenges for hospices caring for patients with very complex or high-cost needs.

  • Impact: The Hospice Benefit has been instrumental in expanding access to end-of-life care in the U.S., allowing millions of Americans to die with dignity and comfort. However, its ‘either/or’ nature (either curative or hospice) has historically been a barrier to earlier access to palliative care, leading to calls for more integrated benefits (National Academies of Sciences, Engineering, and Medicine, 2015).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5.2. Alternative Funding Models and Palliative Care Challenges

While Medicare’s Hospice Benefit is robust, funding for non-hospice palliative care services, which can be provided alongside curative treatments, remains more fragmented and less comprehensively covered. This highlights the need for a diverse array of funding models to ensure universal access to these essential services.

  • Private Insurance: Many private insurance plans now cover some palliative care services, particularly those delivered in outpatient clinics or as hospital consultations. However, coverage can vary widely, often requiring prior authorization and adhering to specific network restrictions. Co-pays and deductibles can also be significant barriers.

  • Medicaid: Medicaid programs vary by state, with some offering comprehensive palliative care benefits, while others have limited or no specific coverage outside of traditional home health or hospice benefits. This creates significant disparities in access based on geography and socioeconomic status.

  • Out-of-Pocket Payments: When services are not covered by insurance, patients and families may have to pay out-of-pocket, which can be a substantial financial burden, exacerbating health inequities.

  • Innovative Models: To address these funding gaps and incentivize quality care, several innovative models are being explored and implemented:

    • Bundled Payments: These models reimburse providers a single, fixed payment for all services related to a specific condition or episode of care (e.g., a hip replacement or a 90-day period post-discharge for heart failure). Bundled payments encourage coordination of care, including palliative services, to reduce complications and rehospitalizations, thereby lowering overall costs while maintaining or improving quality. They shift financial risk from payers to providers, incentivizing efficient, high-value care (hospicenews.com, 2025).
    • Value-Based Care (VBC) and Accountable Care Organizations (ACOs): VBC models reward providers for delivering high-quality, cost-effective care. ACOs are groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. Palliative care, by improving symptom control, reducing unnecessary emergency room visits and hospitalizations, and aligning care with patient preferences, directly contributes to achieving VBC goals. By demonstrating improved outcomes and cost savings, palliative care programs can justify their value within ACO structures.
    • Grants and Philanthropy: Many palliative care programs, especially those in their nascent stages or those serving uninsured populations, rely on grants from foundations, government agencies, and philanthropic donations to sustain their operations and expand services.
    • Direct-to-Consumer/Subscription Models: Emerging models, particularly in home-based palliative care, are exploring subscription-based services or direct payment options for enhanced coordination and support not fully covered by traditional insurance.

  • Policy Implications: There is ongoing advocacy for national palliative care legislation or a specific Medicare palliative care benefit that would cover services much earlier in the disease trajectory, addressing the current gaps. Such policy changes are crucial to ensuring universal access to high-quality, comprehensive palliative and hospice care (Center to Advance Palliative Care, 2023).

UC Davis Health’s integrated division, by demonstrating the clinical and economic value of geriatric and palliative care, is well-positioned to leverage these evolving funding models, securing financial sustainability while expanding access to critical services.

6. Ethical Considerations

The provision of care for older adults and those with serious illnesses is inherently rich with complex ethical dilemmas. Integrating geriatrics, hospice, and palliative medicine necessitates a robust framework for navigating these challenges, ensuring that patient rights, values, and preferences are honored above all else.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.1. Autonomy and Informed Consent – Deeper Exploration

Respect for patient autonomy is the bedrock of hospice and palliative care. Autonomy refers to a patient’s right to make decisions about their own medical care, free from coercion and based on a thorough understanding of their condition, prognosis, and treatment options. This principle is particularly vital in the context of serious illness and end-of-life, where choices can have profound implications for quality of life and dignity.

  • Capacity Assessment: A foundational step is to assess a patient’s decisional capacity – their ability to understand information, appreciate the consequences of their choices, reason, and communicate a decision. This is a clinical determination, not merely a legal one, and can fluctuate due to illness, medications, or cognitive impairment. If capacity is compromised, the process moves to surrogate decision-making.
  • Shared Decision-Making: This is an approach where clinicians and patients work together to make healthcare decisions. It involves the clinician explaining the evidence-based options, discussing the pros and cons of each, and incorporating the patient’s values and preferences into the decision. In palliative care, this is crucial for aligning medical interventions with patient goals.
  • Advance Care Planning (ACP): ACP is a process of communicating and documenting an individual’s wishes regarding future medical treatment, especially if they lose the capacity to make decisions. Key tools include:
    • Advance Directives: Legal documents like a Living Will (specifying treatment preferences) and Durable Power of Attorney for Healthcare (designating a healthcare proxy or agent to make decisions).
    • Physician Orders for Life-Sustaining Treatment (POLST)/Medical Orders for Life-Sustaining Treatment (MOLST): These are actionable medical orders that translate patient preferences for specific life-sustaining treatments (e.g., CPR, ventilation, feeding tubes) into physician orders that are valid across care settings. They are particularly relevant for individuals with serious illnesses or frailty.
    • Designation of a Healthcare Proxy: Appointing a trusted individual to make medical decisions on one’s behalf if one becomes unable to do so. This person should understand the patient’s values and wishes.
  • Communication Strategies: Effective communication is paramount. This includes breaking bad news compassionately, discussing prognosis honestly but sensitively, and exploring patient values and goals. The integrated division emphasizes training providers in empathetic communication techniques to facilitate these challenging conversations (World Health Organization, 2014).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.2. Cultural Sensitivity – Broader Context

Cultural beliefs and practices profoundly shape individuals’ perceptions of health, illness, dying, death, and grief. Delivering person-centered care requires healthcare providers to be culturally competent and, more broadly, culturally humble, recognizing and respecting this diversity to provide personalized and effective care. Neglecting cultural nuances can lead to misunderstandings, mistrust, and care that is misaligned with a patient’s or family’s values.

  • Variations in Illness and Death Perceptions: Cultures differ in how they view illness (e.g., as fate, punishment, or a natural process), their willingness to discuss death openly, and their preferred setting for dying. Some cultures may prefer not to disclose a terminal diagnosis directly to the patient, instead communicating with family members who then mediate information.
  • Family Roles and Decision-Making: In many cultures, healthcare decisions are made collectively by the family rather than solely by the individual patient. Understanding these dynamics is crucial for involving appropriate family members and respecting collective decision-making processes.
  • Spiritual and Religious Beliefs: End-of-life care often brings spiritual questions to the forefront. Providers must be aware of diverse religious practices related to dying, death rituals, dietary restrictions, and spiritual support, ensuring that care respects these deeply held beliefs.
  • Language Barriers: Language differences can impede effective communication and trust. The availability and use of professional medical interpreters are essential to ensure accurate information exchange and shared understanding.
  • Health Disparities: Cultural competence also involves addressing health disparities that disproportionately affect certain racial, ethnic, and socioeconomic groups. These disparities often stem from historical injustices, lack of access to care, and systemic biases (hospicenews.com, 2025). The integrated division aims to deliver equitable care by understanding these underlying factors.
  • Training and Education: Healthcare providers require ongoing training in cultural competence, cultural humility, and unconscious bias to effectively care for diverse populations. This involves learning about common cultural practices, but more importantly, developing the skills to inquire respectfully about individual patient and family preferences without making assumptions.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.3. Justice and Equity

Ethical considerations extend to ensuring fair and equitable access to care. The principle of justice demands that palliative and hospice care resources be distributed fairly, without discrimination based on socioeconomic status, race, ethnicity, sexual orientation, or geographic location. Disparities in access to palliative and hospice care remain a significant challenge, with minority groups, rural populations, and those with lower socioeconomic status often having poorer access and utilization rates (National Academies of Sciences, Engineering, and Medicine, 2015). UC Davis Health’s division must actively work to identify and mitigate these disparities within its service area.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6.4. Ethical Dilemmas in Practice

Integrated care teams frequently encounter difficult ethical dilemmas, requiring careful deliberation and often involving ethics consultations:

  • Withdrawal of Life Support: Decisions to withdraw or withhold life-sustaining treatments (e.g., ventilation, dialysis, artificial nutrition) are some of the most challenging. These require clear communication, understanding patient values, and often involving ethics committees.
  • Medical Aid in Dying (MAID): In jurisdictions where it is legal, discussions around MAID introduce another layer of ethical complexity, requiring adherence to strict protocols, careful assessment of patient capacity, and conscientious objection provisions for providers.
  • Balancing Patient Wishes with Family Desires: Disagreements between patients and families regarding care preferences can be common, requiring skilled mediation and upholding the patient’s autonomous choices if they have capacity.
  • Provider Moral Distress: Healthcare professionals may experience moral distress when they feel unable to provide care that aligns with their ethical principles due to systemic constraints, conflicting demands, or perceived futility of treatment. Institutional support and ethics resources are vital for addressing this.

By prioritizing patient autonomy, fostering cultural sensitivity, striving for equity, and providing robust ethical guidance, UC Davis Health’s integrated division aims to deliver care that is not only clinically excellent but also ethically sound and deeply humane.

7. Common Misconceptions

Despite the growing body of evidence supporting the benefits of palliative and hospice care, widespread misconceptions persist, often acting as significant barriers to early access and optimal utilization. Addressing these misunderstandings is crucial for enhancing public and professional understanding and promoting appropriate referrals.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7.1. Palliative Care is Only for End-of-Life

This is perhaps the most pervasive and damaging misconception. Many healthcare professionals, patients, and families mistakenly believe that palliative care is synonymous with end-of-life care and is only initiated when all curative treatments have failed. This belief often leads to delayed referrals, depriving patients of valuable support during earlier stages of serious illness.

  • Reality: As defined by the World Health Organization and leading palliative care organizations, palliative care can and should be provided at any stage of a serious illness, from the point of diagnosis. Its purpose is to complement curative treatments, not replace them. For instance, a patient undergoing chemotherapy for cancer, managing chronic heart failure, or living with advanced kidney disease can simultaneously benefit from palliative care to alleviate symptoms like pain, nausea, fatigue, and depression. It focuses on improving quality of life concurrently with aggressive disease-modifying therapies (World Health Organization, 2014).
  • Benefits of Early Integration: Research consistently demonstrates that early integration of palliative care can lead to improved symptom control, better quality of life, reduced depression, fewer emergency room visits and hospitalizations, and in some cases, even prolonged survival for certain patient populations (Temel et al., 2010). Delaying palliative care until the very end of life diminishes these potential benefits.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7.2. Hospice Care is Only for Cancer Patients

Another common fallacy is that hospice care is exclusively reserved for individuals with cancer. While oncology patients often represent a significant proportion of hospice admissions, hospice care is designed for anyone with any terminal illness who meets specific eligibility criteria.

  • Reality: Hospice care is appropriate for individuals with any terminal illness with a prognosis of six months or less if the disease runs its natural course. This includes a wide range of conditions beyond cancer, such as:
    • Advanced Heart Failure: Patients with severe, recurrent symptoms despite optimal medical therapy.
    • End-Stage Chronic Obstructive Pulmonary Disease (COPD): Individuals with severe respiratory distress, frequent infections, and progressive functional decline.
    • Advanced Renal Disease: Patients choosing to forego dialysis or those with severe complications despite dialysis.
    • Neurodegenerative Diseases: Conditions like Alzheimer’s disease and other dementias, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis, especially in their advanced stages with significant functional impairment and complex symptom burden.
    • Liver Disease: End-stage liver failure with complications like ascites, encephalopathy, and recurrent infections.
    • Stroke and Coma: Patients with irreversible brain injury or prolonged coma where recovery is unlikely.
  • Focus on Symptom Burden, Not Diagnosis Alone: The key determinant for hospice eligibility is the terminal prognosis and the patient’s symptom burden and functional decline, rather than a specific diagnosis. A patient with severe, uncontrolled symptoms from heart failure, for instance, may benefit immensely from hospice care even if their disease is not cancer (World Health Organization, 2014).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7.3. Palliative/Hospice Means ‘Giving Up’

Many patients and families incorrectly perceive an offer of palliative or hospice care as an admission of defeat or ‘giving up’ on treatment and hope. This perception can be emotionally charged and lead to resistance.

  • Reality: Palliative and hospice care do not mean abandoning hope; rather, they redefine hope. Instead of hoping for a cure that may not be possible, hope shifts to achieving comfort, maintaining dignity, spending quality time with loved ones, and living as fully as possible until the end. It is about actively managing symptoms and maximizing quality of remaining life, which is a proactive and courageous choice, not a surrender. It empowers patients to regain control over their bodies and their care decisions.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7.4. Palliative Care is Too Expensive/Unnecessary

Concerns about the cost of care and the perceived redundancy of palliative services can also be barriers.

  • Reality: Palliative care is often cost-effective. By improving symptom management, enhancing communication, and aligning care with patient preferences, palliative care can reduce unnecessary and expensive interventions, such as frequent emergency room visits, prolonged hospitalizations, and aggressive treatments that do not align with patient goals. Studies have shown that palliative care can lead to significant cost savings while simultaneously improving patient satisfaction and outcomes (May et al., 2018). It is an investment in quality of life that often yields economic benefits as well.

By actively debunking these common myths through public education, professional training, and clear communication, integrated divisions like that at UC Davis Health can facilitate earlier and more appropriate utilization of these vital services, ultimately benefiting patients, families, and the healthcare system as a whole.

8. Impact on Patient Dignity and Family Support

The integration of geriatrics, hospice, and palliative care into healthcare systems like UC Davis Health profoundly impacts the dignity of patients facing serious illness and provides indispensable support for their families. These services fundamentally reshape the experience of illness and dying, moving away from a purely disease-focused approach to one that cherishes the whole person and their relational context.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8.1. Enhancing Patient Dignity

Patient dignity, often defined as a sense of inherent worth and respect, is frequently challenged by serious illness, which can strip individuals of their independence, control, and personal identity. Integrated geriatric and palliative care actively works to preserve and enhance dignity through several key mechanisms:

  • Personalized, Patient-Centered Care: Dignity is upheld when care is tailored to the individual’s unique values, preferences, and life story. Palliative care’s emphasis on understanding ‘what matters most’ to the patient ensures that decisions reflect their deepest desires, whether it is spending time with family, maintaining comfort, or achieving specific personal goals. This contrasts with a one-size-fits-all medical approach.
  • Respect for Autonomy and Control: By facilitating advance care planning and engaging in shared decision-making, patients retain control over their medical journey, even in the face of declining health. Making informed choices, such as accepting hospice care or refusing aggressive treatments, empowers patients and reinforces their autonomy, which is crucial for preserving self-worth.
  • Aggressive Symptom Management: Uncontrolled pain, nausea, breathlessness, or other distressing symptoms can be profoundly undignifying, reducing a person to their suffering. Expert symptom management, a hallmark of palliative and hospice care, restores physical comfort, allowing patients to engage with their lives and loved ones more fully. This enables patients to maintain their physical and emotional presence, which is central to their sense of self.
  • Preservation of Identity and Legacy: Palliative care often includes psychosocial and spiritual support that helps patients reflect on their lives, find meaning, reconcile relationships, and express their wishes for their legacy. This can involve life review, spiritual counseling, or simply creating an environment where patients feel seen and heard as individuals beyond their illness. The interdisciplinary team ensures that the patient’s story and identity are recognized and respected.
  • Compassionate Communication: Open, honest, and empathetic communication from providers about prognosis, treatment options, and goals of care is vital. This respectful dialogue affirms the patient’s intelligence and right to know, fostering trust and reducing anxiety, thereby contributing to their sense of dignity. The ability to ask questions, voice fears, and have them acknowledged validates their experience.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8.2. Comprehensive Family Support

Serious illness does not affect just the patient; it deeply impacts their entire family unit. Integrated care provides comprehensive support to families, recognizing their critical role as caregivers, decision-makers, and grieving loved ones. This support is multifaceted:

  • Alleviation of Caregiver Burden: Family caregivers often face immense physical, emotional, and financial strain. Geriatric and palliative care teams provide practical support, education on patient care, respite services (especially in hospice), and emotional counseling. By supporting the caregiver, they enable them to provide better care and reduce their risk of burnout and depression.
  • Effective Communication and Education: Family meetings with the interdisciplinary team provide a structured forum for discussing the patient’s condition, treatment plans, and goals of care. This ensures that families are well-informed, have their questions answered, and are included in decision-making processes, reducing misunderstanding and conflict. Education on disease progression and what to expect during the dying process prepares families mentally and emotionally.
  • Emotional and Psychosocial Support: Social workers and chaplains within the team offer counseling, crisis intervention, and emotional support to family members grappling with grief, anxiety, and stress. This includes facilitating difficult conversations and providing a safe space for emotional expression.
  • Bereavement Support Programs: Hospice services, in particular, include structured bereavement support for families for up to one year after the patient’s death. This can involve individual counseling, support groups, remembrance events, and resources to help navigate the grieving process. This proactive approach acknowledges that grief is a natural, albeit painful, part of loss and provides a lifeline to families during a vulnerable time.
  • Facilitating a Peaceful Dying Process: By ensuring optimal symptom control and a supportive environment, integrated care helps facilitate a peaceful and dignified dying process for the patient, which profoundly impacts the family’s ability to cope with loss and remember their loved one without the trauma of uncontrolled suffering. This often contributes to healthier grieving outcomes for survivors.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8.3. Broader Societal Impact

Beyond individual patients and families, the integration of these services has a broader societal impact. It helps normalize discussions about serious illness, dying, and death, shifting away from a culture of avoidance. By demonstrating how compassionate, holistic care can improve outcomes and reduce suffering, it fosters a more humane approach to healthcare for everyone (World Health Organization, 2014). The interdisciplinary approach cultivated by such a division creates a supportive environment that enhances the overall well-being of patients and their loved ones, setting a new standard for comprehensive care in an aging world.

9. Conclusion

The establishment of the Division of Geriatrics, Hospice, and Palliative Medicine at UC Davis Health represents a pivotal and progressive stride toward realizing truly integrated, patient-centered care for older adults and individuals grappling with serious, life-limiting illnesses. This strategic unification of specialties is not merely an organizational restructuring but a philosophical commitment to addressing the intricate and evolving health challenges of an aging population through a comprehensive, proactive, and compassionate lens. By bringing together the nuanced understanding of geriatric syndromes, the expert symptom management of palliative care, and the holistic end-of-life support of hospice, UC Davis Health is creating a model designed to enhance quality of life, alleviate suffering, and uphold patient dignity across the entire illness trajectory.

The division’s objectives are multifaceted: to streamline complex care pathways, thereby reducing the fragmentation often experienced by older adults with multimorbidity; to enhance interdisciplinary collaboration among physicians, nurses, social workers, chaplains, and other allied health professionals; and critically, to address the persistent national shortage of geriatric and palliative care specialists through robust fellowship programs. This integrated educational approach ensures that future healthcare leaders are equipped with a holistic understanding of care that spans healthy aging to bereavement support.

Furthermore, this report has illuminated the foundational principles that guide these specialties – particularly the emphasis on patient autonomy, informed consent, and shared decision-making, exemplified by comprehensive advance care planning. It has underscored the imperative of cultural sensitivity and justice, acknowledging the diverse beliefs and experiences that shape patients’ perceptions of illness and end-of-life. By actively confronting and dispelling common misconceptions about palliative and hospice care, the division aims to foster earlier engagement, ensuring that patients and families can access these vital services when they will have the most significant impact.

The service delivery models within this integrated framework, encompassing inpatient, outpatient, and home-based care, are designed to provide continuity and adaptability, ensuring that care is delivered in the most appropriate and comfortable setting. While funding mechanisms for palliative care remain a complex landscape, the division’s innovative approach positions it to leverage emerging value-based care models and demonstrate the economic as well as humanistic benefits of integrated care, potentially reducing overall healthcare costs by preventing unnecessary hospitalizations and interventions.

Ultimately, the profound impact of this integration lies in its ability to enhance patient dignity by upholding autonomy, alleviating suffering, and validating individual worth. Concurrently, it provides comprehensive, compassionate support for families, recognizing their critical role and alleviating the burdens of caregiving and grief. The UC Davis Health model serves as a potential blueprint for other healthcare systems worldwide seeking to enhance the quality of care for individuals with serious illnesses. It underscores the vital importance of clinical excellence, education, and compassionate support in promoting healthy aging, improving patient outcomes, and fostering a healthcare culture that truly honors the human experience from beginning to end.

References

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