what i have heard is very different from what i am accustomed to hearing from my training in terms of palliative care . one of the things that bothered me a lot about bringing up palliative care , and i was one of the most aggressive residents about doing this , was that patients had to sign a form saying they understood that they would no longer be getting certain aspects of care . your presentation gave the impression that palliative care can be applied much earlier , and even as part of regular ongoing treatment , which sounds terrific to me . when i was in the hospital , i had the sense that the palliative care team was the only group of people who are advocating for patients or family members with the day - to - day problems such as getting blood drawn every 30 minutes , getting woken up 20 times a night , and other things that just make life in the hospital miserable . are there ways palliative medicine can address some of these more practical issues ? and how does it work ? it seems very awkward when the team that is dealing with the acute problems is the one asking for blood every 30 minutes . mir s response : it is very important to know that we , as palliative care team , have a very big role in the hospital . we have to speak to the patient and the family and conduct a family meeting . the next goal is to speak to the physicians and the consultants and having a series of grand rounds for the subspecialties : the cardiologists , heart failure specialists , and neurologists . unfortunately , we have a specialty for each system and each disease of the body . i think it is a very productive exercise in the sense that a lot of questions are answered , and the subspecialists are able to understand what we do in a better sense . we collaborate with them because we tell them that we are meeting the family of a patient . we recently had a very sad case of west nile virus with multiorgan failure , and in the patient s family there were two health - care workers whom we knew closely . the patient s wishes were clear about not having life - sustaining therapies , but he did not have the capacity at the time to make this known . through the negotiation of goals of care , the only way we could deliver what was needed to the family was to have the neurologist in the room to present all the information we could , both from centers for disease control and prevention and from the new york state department of health . we asked the family members what they wanted and what kind of outcomes they were looking for . it does not limit therapies ; for example , palliative care can partner with oncology care . hospice has open - access , which means hemodialysis or palliative chemotherapy can be offered under the hospice benefit . as long as the focus is symptom palliation , we do whatever it takes to make that patient comfortable . dr . mir s response : the hospice benefit recommends that patient sign a waiver to forego aggressive treatment . smith pointed out that hospice gets paid $ 174 a day to cover certain services . those services are for durable medical equipment , including a bed , oxygen , and whatever else is needed , including lab tests and nurse visits . they include wound care , which may be daily , and may include hydration and nutrition . therefore , the cost may be way beyond $ 174 . it is a balancing act to see what is appropriate for each patient and trying to individualize the plan of care . clearly , a time will come that we will have programs or plans for medicare , which is called bridge to hospice . i think the data from the new england journal of medicine s article will show that we can have good palliation and good symptom control along with chemotherapy in improving the patients outcomes .
health care should make an attempt to understand the different religious principles that affect end - of - life decisions in patient care 
 . with advanced illness , defining an ethical framework is essential to understanding sensitive issues . 
 compassionate care is crucial in all end - of - life care settings . 
 physician awareness is a key principle in inculcating the religious values of patients . 
 cultural and religious awareness on the part of the health - care team is needed to provide patients with effective end - of - life palliative and hospice care .