The home hospice care team at Taipei Veterans General Hospital has been dedicated to providing palliative care for residents of Veterans Homes during the final stages of their lives. To date, the team has facilitated dignified end-of-life care for over 100 residents.
With the support of the Hospice Foundation of Taiwan’s palliative care advocacy, education, and research programs, the team has reviewed and analyzed past medical records. The goal is to develop a scale more aligned with the practical care needs in long-term care institutions, enabling the early identification of patients approaching the end of life or requiring palliative care, thereby providing timely and appropriate care.
In long-term care institutions, the sound of ambulances transporting residents to the hospital is a common occurrence. Whenever a resident experiences a health emergency, they are promptly sent to the hospital for treatment. However, when medical interventions no longer align with the resident’s needs and instead place an additional burden on them, we must pause and consider: what kind of care does the resident truly desire? Would they prefer to remain in the comfort of their familiar surroundings with caregivers they know? Medical training often focuses on relieving patients’ suffering and extending their lives, but seldom teaches us how to balance these when prolonging life may also extend the dying process.
Currently, Taiwan has 16 Veterans Homes, which for many residents serve as their second home. These veterans, who have dedicated their lives to serving the country, often wish to spend their remaining years at the Veterans Home and pass away there with dignity. This makes the promotion of palliative care within long-term care facilities especially significant. The goal is not merely to allow residents to die at the Veterans Home, but to help them reduce suffering in their final days, achieve physical, mental, and spiritual peace, and ensure that their families can say their farewells in a meaningful way—attaining peace for both the living and the deceased.
As of now, about 50 residents at the Taipei Veterans Home are receiving palliative care, with an average admission age of over 90. The Taipei Veterans General Hospital’s home hospice care team provides regular visits by doctors and nurses, assists with comfort care, and conducts palliative care family meetings to understand the resident's preferences and set end-of-life care goals.
Comprehensive Care Through Family Meetings
The promotion of palliative care has faced many obstacles, particularly with frontline institutional staff who often hold misconceptions about caring for terminally ill patients. These staff members may lack experience in end-of-life care and fear the unpredictability of the dying process. This makes palliative care education all the more essential. It is of utmost importance to provide practical training courses in palliative care to Veterans Home staff, covering aspects such as addressing common psychosocial and spiritual needs of terminal patients, managing end-of-life symptoms, and assessing signs in the final stages of life.
In the staff training courses, learning to identify residents in need of palliative care is the first step. In addition to terminal cancer patients, many elderly residents with non-cancer conditions often suffer from dementia or multiple chronic comorbidities. Although they may seem stable in their daily lives, issues like weight loss or a single severe infection or fall can significantly reduce their functional abilities. This makes it difficult for staff to recognize the appropriate time for early palliative care intervention.
Family meetings have always been a cornerstone of palliative care. At various stages of a resident's illness, all concerned parties, including family members, Veterans Home supervisors, ward leaders, nurses, and the Taipei Veterans General Hospital’s home hospice care team participate in family meetings. The team explains the resident's current conditions, potential developments, and recommended medical care plans. If the residents are conscious, they also participate, discussing their values, wishes, and the family’s perspectives, which include preferred end-of-life settings and the extent of life-saving measures like CPR. Every family meeting reveals a unique life story, with the experiences and wisdom shared by the Veterans Home residents and their families helping the team to provide care that best aligns with the residents’ needs. Family meetings may occur multiple times, allowing for adjustments to the medical and care goals as the residents’ condition evolves.
Skillful Use of “Comfort Packs” for Peaceful End-of-Life Care
The Taipei Veterans General Hospital’s home hospice care team conducts regular visits, integrating palliative care into daily routines. This approach is like adding a partner that works together to improve the resident’s quality of life. The team provides comprehensive comfort care, including wound care, lymphatic massage, oral hygiene, and hand and foot care. Doctors also prescribe preventive medications tailored to the resident’s condition to quickly and effectively relieve discomfort. These medications are collectively referred to as “Comfort Packs,” which helps reduce emergency room visits and hospital admissions for terminally ill residents, improving their quality of life and allowing them to peacefully pass away at the Veterans Home.
Supported by the Hospice Foundation of Taiwan’s palliative care advocacy, education, and research programs, the Taipei Veterans General Hospital’s home hospice care team reviewed data from November 2018 to September 2022. A total of 90 residents passed away at the Veterans Home during this period, with the data showing:
- 96.7% were male, with an average age of 92, and 27.8% were single veterans.
- 28.9% had a cancer diagnosis, while 48.9% were diagnosed with dementia.
- 7.8% had signed advance healthcare directives.
- The average duration from palliative care admission to death was 144.9 days.
The analysis revealed that, regardless of whether residents had cancer or not, respiratory distress was the most common terminal symptom among the elderly, affecting approximately 67.8% of residents before death. Oral morphine was the most frequently prescribed and used medication in the Comfort Packs, primarily for alleviating respiratory distress and pain. All Comfort Pack medications were prescribed in advance during regular doctor visits, aimed to alleviate potential discomforts such as:
- Fever: antipyretics or antibiotics prescribed
- Respiratory distress or pain: morphine prescribed
- Agitation or delirium: sedatives or antipsychotics prescribed
The study also highlighted the importance of respiratory care skills for long-term care facility staff in end-of-life care. Proper use and timing of Comfort Pack medications are essential components of staff education and training.
Enhancing Care Quality by Integrating Palliative Care with Long-Term Care
Ms. Chia-Miao Hong, a supervisor at Taipei Veterans Home, once said, "Caring is like a relay race; the facility is the resident's final stop. When the family hands over the baton to us, we need to help them run to the finish line of life." Families expect the facility to provide better care and quality of life for the residents. By integrating palliative care into long-term care, the quality of care can be enhanced, but families often have limited understanding of palliative care. Promoting palliative care requires teamwork: long-term care staff need to receive on-the-job training in palliative care, while residents and their families should engage in life education to learn how to take responsibility for their own lives.
If long-term care facilities can combine palliative care and proactively communicate care goals with residents or their families, it will not only improve the quality of end-of-life care for residents but also increase family satisfaction with the facility’s services. This allows residents to say their goodbyes in a meaningful way, making the end of life a moment filled with blessings and emotion, rather than a sudden, unprepared event.
I’ll never forget the profound impact of witnessing the first resident pass away peacefully at the Veterans Home. Though it may seem like a small step, it was a significant leap forward for both our home hospice care team and the facility. The small, seemingly trivial things we do can bring immense satisfaction to residents. Simple acts like daily cleaning, comforting massages, and other forms of care become great sources of enjoyment for them. The anticipation of a bowl of corn soup or the joy of sipping a beer with a side dish brings smiles to the veterans’ faces, which gives us tremendous encouragement and the motivation to keep going.
There is never a perfect time to say goodbye to a loved one. There will always be feelings of sadness and reluctance. What matters most is how we accompany them through this journey—expressing gratitude, offering apologies, showing love, and bidding farewell. Walking this final path with residents and their families is the most precious part of our work. We are deeply grateful to every resident who has entrusted us with their last days at the Veterans Home. The Taipei Veterans General Hospital’s home hospice care team will continue to strive to assist more people in need.