End-of-Life & Palliative Care
End-of-Life & Palliative Care
MANDATORY
5 criteria
| Standard 6.1 NON-NEGOTIABLE · Standard 6: End-of-Life & Palliative Care Advance Directives Are Discussed Proactively, Not Only When a Crisis Arrives |
ASSESSMENT ASF-LTC-STD6-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 6.1 NON-NEGOTIABLE L1 |
THE STANDARD Advance Directives Are Discussed Proactively, Not Only When a Crisis Arrives Every resident, or their legal representative, is proactively offered a genuine conversation about advance directives and life-sustaining treatment preferences at admission and periodically thereafter — not first raised during a medical crisis, when there is far less time and far more distress to make a considered decision. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is every resident or representative proactively offered a genuine advance directive conversation at admission? A real, offered conversation, not paperwork provided without discussion. Doc: Advance directive conversation record |
YES | PARTIAL | NO |
| 2 | Is this conversation revisited periodically, not held once and never referenced again? Genuine, periodic revisiting, not a single admission-only conversation. Doc: Periodic review record |
YES | PARTIAL | NO |
| 3 | Are documented preferences genuinely accessible to staff at the moment they're actually needed? Real, practical accessibility in a genuine emergency, not a document filed away and hard to locate. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Advance directive conversation review |
Reviews documentation of genuine, proactive advance directive conversations at admission. |
| DOCUMENT Periodic review record check |
Reviews evidence that advance directive preferences are genuinely revisited over time. |
| OBSERVE Accessibility check |
Checks whether documented preferences would actually be accessible to staff during a real emergency. |
REFERENCES
- [26] The United Nations Principles for Older Persons establish the right of older persons to make decisions about their own care, a principle reflected in established long-term care practice as the resident's right to formulate advance directives, with the facility required to provide written information about these rights and to address resident complaints about facility non-compliance.
| Standard 6.1 · Standard 6: End-of-Life & Palliative Care Guidance & Learning |
GUIDANCE ASF-LTC-STD6-v3.0 |
| WHY THIS STANDARD EXISTS |
A decision about life-sustaining treatment made in the middle of a medical crisis, under real time pressure and emotional strain, is a fundamentally worse decision-making context than a calm, proactive conversation held well in advance — the resident's actual wishes deserve to be captured when there's genuinely time to consider them.
| WHAT GOOD LOOKS LIKE ✓ Every resident or representative receives a genuine, proactive advance directive conversation. ✓ Preferences are periodically revisited, not captured once and forgotten. ✓ Documentation is genuinely accessible to staff when actually needed. |
WHAT FAILURE LOOKS LIKE ✗ Advance directives are raised only during a medical crisis, if at all. ✗ Preferences are captured once at admission and never revisited. ✗ Documentation exists but isn't practically accessible in a real emergency. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 The conversation happens at admission but isn't revisited even after a significant change in the resident's condition.
A resident's preferences, or their ability to express them, can genuinely change over time.
2 Documentation is thorough but stored in a way that's slow to locate during an actual emergency.
Documentation that exists but isn't practically accessible in the moment provides limited real protection.
3 Conversations happen with legal representatives but the resident themselves, where capable, isn't directly included.
A capable resident deserves genuine inclusion in decisions about their own end-of-life care.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current advance directive practice for genuine proactive conversation versus paperwork alone.
Week 2 Establish a periodic review schedule for advance directive preferences.
Week 3 Confirm documentation is genuinely, practically accessible during an emergency.
Ongoing Revisit preferences after any significant change in resident condition.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask staff how quickly they could locate a specific resident's advance directive during a real emergency.
A specific, confident answer reveals genuine practical accessibility, not just documentation existing somewhere.
Ask a resident or family member whether the conversation felt genuine, not just a form to sign.
This tests lived experience of the conversation, not documentation compliance alone.
| E-LEARNING academy.gmj.ge/ltc-std6-1-advance-directives — 30 min · complete before self-assessment |
| Standard 6.2 NON-NEGOTIABLE · Standard 6: End-of-Life & Palliative Care Palliative Care Is Available Regardless of Terminal Diagnosis |
ASSESSMENT ASF-LTC-STD6-v3.0 |
| CR ADAPTED | TR FULL | SM ADAPTED | ST FULL |
| 6.2 NON-NEGOTIABLE L1 |
THE STANDARD Palliative Care Is Available Regardless of Terminal Diagnosis Palliative care — addressing physical, emotional, social, and spiritual suffering — is genuinely available to any resident who could benefit, not restricted to residents with a terminal diagnosis or treated as identical to, and conditional upon, hospice enrollment. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is palliative care genuinely available to any resident who could benefit, not restricted to those with a terminal diagnosis? Real availability independent of terminal prognosis, not conflated with hospice eligibility. Doc: Palliative care availability documentation |
YES | PARTIAL | NO |
| 2 | Do staff genuinely understand the distinction between palliative care and hospice, not treat them as interchangeable? Genuine, accurate understanding of the real distinction, not confusion between the two. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Does palliative care genuinely address physical, emotional, social, and spiritual suffering, not medical pain management alone? The full, genuine scope of palliative care, not a narrowed version limited to physical symptoms. Doc: Palliative care scope documentation |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Availability review |
Reviews whether palliative care is genuinely available independent of terminal diagnosis status. |
| ASK Staff distinction interview |
Asks staff to explain the actual difference between palliative care and hospice. |
| DOCUMENT Scope review |
Reviews palliative care documentation for genuine coverage beyond physical symptom management alone. |
REFERENCES
- [27] Established international clinical definitions of palliative care describe it as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering, addressing physical, intellectual, emotional, social, and spiritual needs, distinct from and not conditional upon a terminal diagnosis or hospice election.
| Standard 6.2 · Standard 6: End-of-Life & Palliative Care Guidance & Learning |
GUIDANCE ASF-LTC-STD6-v3.0 |
| WHY THIS STANDARD EXISTS |
Palliative care and hospice are genuinely different things — palliative care requires no terminal prognosis at all, and a resident recovering from a serious injury or managing chronic pain can benefit from it just as much as someone with a terminal diagnosis. A facility that conflates the two, or makes palliative care conditional on a terminal diagnosis, denies real comfort-focused care to residents who could genuinely benefit from it.
| WHAT GOOD LOOKS LIKE ✓ Palliative care is genuinely available regardless of terminal diagnosis. ✓ Staff accurately understand and can explain the real distinction from hospice. ✓ Palliative care genuinely addresses the full range of suffering, not physical symptoms alone. |
WHAT FAILURE LOOKS LIKE ✗ Palliative care is treated as available only for residents with a terminal diagnosis. ✗ Staff conflate palliative care with hospice, treating them as the same thing. ✗ Palliative care is narrowed to physical pain management alone. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Physical symptom management is genuinely available broadly but emotional and spiritual support is less consistently offered.
Genuine palliative care addresses the full range of suffering, not physical symptoms in isolation.
2 Some staff understand the real distinction from hospice but others use the terms interchangeably.
Consistent, accurate understanding across the full care team matters for residents to receive appropriate access.
3 Palliative care is offered when a resident or family specifically asks but not proactively identified as an option.
A resident or family may not know to ask if they're not aware palliative care is a genuinely separate, broader option.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current palliative care access for genuine independence from terminal diagnosis status.
Week 2 Train staff specifically on the real distinction between palliative care and hospice.
Week 3 Expand palliative care scope to genuinely address emotional, social, and spiritual suffering.
Ongoing Proactively identify and offer palliative care to residents who could genuinely benefit.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a staff member to explain the actual difference between palliative care and hospice.
A clear, accurate answer reveals genuine understanding, not assumed familiarity.
Ask about palliative care for a resident without a terminal diagnosis specifically.
This tests whether availability is genuinely independent of terminal status, not conflated with hospice eligibility.
| E-LEARNING academy.gmj.ge/ltc-std6-2-palliative-care-access — 30 min · complete before self-assessment |
| Standard 6.3 NON-NEGOTIABLE · Standard 6: End-of-Life & Palliative Care Hospice Coordination Follows a Real, Written Agreement, Not Informal Handoff |
ASSESSMENT ASF-LTC-STD6-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 6.3 NON-NEGOTIABLE L1 |
THE STANDARD Hospice Coordination Follows a Real, Written Agreement, Not Informal Handoff When a resident elects hospice care, the facility and the hospice agency operate under a specific, written agreement clearly defining who is responsible for each service — not an informal handoff where responsibility gaps go unnoticed until something is missed. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is there a specific, written agreement with the hospice agency defining responsibility for each service? A real, specific written agreement, not an informal or assumed division of responsibility. Doc: Hospice coordination agreement |
YES | PARTIAL | NO |
| 2 | Can staff clearly identify who is responsible for a specific aspect of a hospice resident's care? Specific, confident knowledge of the actual division of responsibility, not uncertainty or assumption. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is there a real, documented process for identifying and closing a coordination gap if one is discovered? An active process for catching gaps, not an assumption the written agreement alone prevents them. Doc: Coordination gap identification process |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Written agreement review |
Reviews the actual written agreement with the hospice agency for specific responsibility definitions. |
| ASK Staff responsibility interview |
Asks staff to identify who is responsible for a specific element of a current hospice resident's care. |
| DOCUMENT Gap identification process review |
Reviews the process for identifying and closing coordination gaps between facility and hospice. |
REFERENCES
- [28] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require a written agreement between the facility and any hospice or palliative care service specifying which entity is responsible for each element of the resident's care.
| Standard 6.3 · Standard 6: End-of-Life & Palliative Care Guidance & Learning |
GUIDANCE ASF-LTC-STD6-v3.0 |
| WHY THIS STANDARD EXISTS |
When hospice care begins, two separate organizations become responsible for the same resident at the same time, and coordination gaps between them are a genuine, well-documented quality problem — a written agreement specifying who does what isn't bureaucratic formality, it's what actually prevents a resident falling through a gap between two providers who each assume the other is handling something.
| WHAT GOOD LOOKS LIKE ✓ A specific, written agreement clearly defines responsibility for each service. ✓ Staff can confidently identify who is responsible for specific aspects of care. ✓ A real process exists for identifying and closing coordination gaps. |
WHAT FAILURE LOOKS LIKE ✗ Coordination relies on informal or assumed division of responsibility. ✗ Staff are uncertain who is responsible for specific hospice resident care needs. ✗ No process exists for identifying gaps before they result in a missed need. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 The written agreement is comprehensive but staff aren't fully familiar with its specific terms.
An agreement that exists but isn't genuinely known by staff provides limited real coordination benefit.
2 Responsibility is clear for medical care but less clear for personal care and daily support.
Every category of care needs the same clear definition to prevent a genuine gap.
3 A gap identification process exists but hasn't been genuinely tested with a real coordination issue.
An untested process may not function smoothly when an actual gap needs to be caught and closed.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current hospice coordination agreements for specific, comprehensive responsibility definitions.
Week 2 Brief staff thoroughly on the specific terms of the agreement.
Week 3 Establish a real process for identifying and closing coordination gaps.
Ongoing Review hospice coordination for any real gaps that emerge in practice.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see the actual written agreement for a current or recent hospice resident.
A specific, real document is the evidence of genuine coordination, not an assumed arrangement.
Ask a staff member a specific question about who handles a particular need for a hospice resident.
A confident, specific answer reveals genuine clarity, not uncertainty papered over.
| E-LEARNING academy.gmj.ge/ltc-std6-3-hospice-coordination — 30 min · complete before self-assessment |
| Standard 6.4 NON-NEGOTIABLE · Standard 6: End-of-Life & Palliative Care Pain and Suffering Are Actively Anticipated and Treated, Not Just Responded To |
ASSESSMENT ASF-LTC-STD6-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 6.4 NON-NEGOTIABLE L1 |
THE STANDARD Pain and Suffering Are Actively Anticipated and Treated, Not Just Responded To A resident's pain and suffering — physical, emotional, social, spiritual — are actively anticipated and proactively addressed as part of ongoing care, not left until the resident reports significant distress, particularly for residents whose cognitive or communication impairment makes reporting pain genuinely difficult. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is pain and suffering actively, proactively assessed, not only addressed when a resident reports distress? Genuine, proactive assessment, not reliance on the resident to initiate a report. Doc: Proactive pain assessment documentation |
YES | PARTIAL | NO |
| 2 | Is there a specific approach for assessing pain in residents whose cognitive or communication impairment makes self-reporting difficult? A specific, adapted assessment approach, not the same self-report method applied regardless of communication ability. Doc: Non-verbal pain assessment tool |
YES | PARTIAL | NO |
| 3 | Does assessment genuinely cover emotional, social, and spiritual suffering, not physical pain alone? The full, genuine scope of suffering, not narrowed to physical symptoms. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Proactive assessment review |
Reviews documentation for genuine, scheduled proactive pain and suffering assessment. |
| DOCUMENT Non-verbal assessment tool review |
Reviews the specific tool or approach used for residents with communication impairment. |
| OBSERVE Scope observation |
Observes whether assessment genuinely covers emotional, social, and spiritual dimensions, not physical pain alone. |
REFERENCES
- [29] Established international clinical definitions of palliative care describe anticipating, preventing, and treating suffering as central to genuine palliative practice, distinct from reactive response to reported distress alone.
| Standard 6.4 · Standard 6: End-of-Life & Palliative Care Guidance & Learning |
GUIDANCE ASF-LTC-STD6-v3.0 |
| WHY THIS STANDARD EXISTS |
A resident who cannot easily communicate — due to cognitive impairment, illness, or the dying process itself — is at real risk of experiencing significant pain or suffering that goes unaddressed simply because it wasn't actively looked for, and waiting for a resident to report distress fails exactly the residents least able to do so.
| WHAT GOOD LOOKS LIKE ✓ Pain and suffering are proactively, genuinely assessed on a regular basis. ✓ A specific, adapted assessment approach exists for residents with communication impairment. ✓ Assessment genuinely covers the full range of suffering, not physical symptoms alone. |
WHAT FAILURE LOOKS LIKE ✗ Assessment happens only when a resident reports distress themselves. ✗ The same self-report method is used regardless of a resident's actual communication ability. ✗ Assessment is narrowed to physical pain, ignoring emotional, social, or spiritual suffering. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Proactive assessment happens for residents who can self-report but relies on observation alone for those who cannot, without a structured tool.
A structured, validated approach for non-verbal residents provides more reliable identification than observation alone.
2 Physical pain is proactively assessed but emotional and spiritual suffering are addressed only reactively.
The full scope of suffering deserves the same proactive attention as physical pain specifically.
3 A non-verbal assessment tool exists but isn't consistently used by all staff.
Consistent use across all staff is what makes a structured tool genuinely reliable in practice.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current pain and suffering assessment practice for genuine proactive versus reactive approach.
Week 2 Establish or strengthen a structured, validated assessment tool for non-verbal residents.
Week 3 Expand assessment scope to genuinely cover emotional, social, and spiritual suffering.
Ongoing Audit assessment consistency across all staff and shifts.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask what specific tool is used to assess pain in a resident who cannot verbally communicate.
A specific, named tool reveals genuine, structured practice, not reliance on informal observation.
Ask how emotional or spiritual suffering is proactively identified, not just physical pain.
This tests whether the full scope of suffering is genuinely addressed.
| E-LEARNING academy.gmj.ge/ltc-std6-4-proactive-suffering-assessment — 30 min · complete before self-assessment |
| Standard 6.5 CORE · Standard 6: End-of-Life & Palliative Care Family Is Genuinely Included in End-of-Life Decisions, Not Just Informed |
ASSESSMENT ASF-LTC-STD6-v3.0 |
| CR N/A | TR FULL | SM ADAPTED | ST FULL |
| 6.5 CORE L1 |
THE STANDARD Family Is Genuinely Included in End-of-Life Decisions, Not Just Informed Family members are genuinely included as participants in end-of-life care decisions and planning conversations — not merely informed of decisions after they've already been made by clinical staff. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Are family members genuinely included as participants in end-of-life decisions, not just informed afterward? Real, participatory inclusion, not notification of decisions already finalized. Doc: Family participation documentation |
YES | PARTIAL | NO |
| 2 | Are family members given genuine opportunity to ask questions and express concerns before decisions are finalized? A real opportunity before finalization, not a decision presented as already settled. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Do families report feeling genuinely included, not just informed, in end-of-life decision-making? Real, reported experience of inclusion, not assumed from the process alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Family participation review |
Reviews documentation for genuine family participation in end-of-life planning, not just notification. |
| OBSERVE Decision-making process observation |
Observes an actual or simulated end-of-life planning conversation for genuine family inclusion. |
| ASK Family experience interview |
Asks a family member whether they felt genuinely included in decision-making, not just informed. |
REFERENCES
- [30] Genuine family participation in end-of-life care decision-making, distinct from notification of decisions already made, is established practice in palliative and end-of-life care literature for both improving decision quality and supporting family wellbeing through the experience.
| Standard 6.5 · Standard 6: End-of-Life & Palliative Care Guidance & Learning |
GUIDANCE ASF-LTC-STD6-v3.0 |
| WHY THIS STANDARD EXISTS |
For most families, a resident's end-of-life period is one of the most significant experiences they'll share with that person, and genuine inclusion in decision-making — not just being told what's already been decided — matters both for making decisions that truly reflect the resident's wishes and for the family's own experience of this time.
| WHAT GOOD LOOKS LIKE ✓ Family members are genuine, active participants in end-of-life decisions. ✓ Families have real opportunity to ask questions and raise concerns before decisions are finalized. ✓ Families report feeling genuinely included, not just informed. |
WHAT FAILURE LOOKS LIKE ✗ Family members are informed of decisions after clinical staff have already finalized them. ✗ No real opportunity exists for family questions or concerns before finalization. ✗ Families report feeling excluded or only nominally consulted. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Inclusion is genuine for major decisions but day-to-day comfort care adjustments aren't discussed with family.
Ongoing comfort care decisions matter to families too, not only major turning points.
2 Family is included when readily available but less consistently when family members live at a distance.
Genuine inclusion shouldn't depend on a family member's physical proximity or availability.
3 Conversations happen but families report feeling rushed rather than genuinely heard.
The quality and pace of the conversation matters as much as whether it technically occurred.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current end-of-life decision-making practice for genuine family participation versus notification.
Week 2 Establish a process ensuring family opportunity to ask questions before decisions are finalized.
Week 3 Build accommodations for family members at a distance to genuinely participate.
Ongoing Gather family feedback on their genuine experience of inclusion in decision-making.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a family member directly whether they felt genuinely included, not just informed.
This tests lived experience, not process compliance alone.
Ask how a family member living at a distance would genuinely participate in a decision conversation.
This reveals whether inclusion is genuinely accessible, not dependent on physical presence.
| E-LEARNING academy.gmj.ge/ltc-std6-5-family-inclusion — 30 min · complete before self-assessment |
Long-Term Care Standards — overviewFacility Classification — Which Type of Facility Are You?Standard 1 — Admission & Resident RightsStandard 2 — Living Environment & SafetyStandard 3 — Personal Care & Daily LivingStandard 4 — Clinical & Medical CareStandard 5 — Cognitive & Behavioral CareStandard 6 — End-of-Life & Palliative CareStandard 7 — Governance & StaffingStandard 8 — Medical TourismStandard 9 — Health & MigrationReferences & Index
STANDARD 6End-of-Life & Palliative Care6.1 Advance Directives Are Discussed Proactively, Not Only When a Crisis Arrives6.2 Palliative Care Is Available Regardless of Terminal Diagnosis6.3 Hospice Coordination Follows a Real, Written Agreement, Not Informal Handoff6.4 Pain and Suffering Are Actively Anticipated and Treated, Not Just Responded To6.5 Family Is Genuinely Included in End-of-Life Decisions, Not Just Informed
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