AbstrAct:The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidencebased care that improves patient outcomes such as health-related quality of life and is consistent with the patients' values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient-and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient's family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payerprovider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

pproximately 11.3 million undocumented immigrants live and work in the United States. 1 Because this lowincome population is excluded from a range of public benefits that include Medicare, federally funded Medicaid, and the insurance provisions of the Affordable Care Act, undocumented immigrants are a significant portion of the post-Affordable Care Act population who remain uninsured. 2 Their access to health care is limited largely to safety-net provisions for the uninsured, chiefly, nonprofit community health centers, public clinics, and emergency treatment in hospital emergency departments (EDs) mandated by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). 2,3 Arranging care is especially complex when an undocumented immigrant is diagnosed with end-stage renal disease (ESRD), for which hemodialysis is a life-sustaining treatment. 4,5 Undocumented immigrants' ineligibility for public benefits means they cannot access the diagnostically based Medicare entitlement for hemodialysis. 6 An estimated 6480 undocumented immigrants in the United States have ESRD. 7 Their access to hemodialysis depends on state policy and local safetynet investments. Some states, including California and New York, use state emergency Medicaid programs to finance scheduled hemodialysis for these patients. 8,9 Most states, including some with large undocumented immigrant populations, IMPORTANCE The exclusion of undocumented immigrants from Medicare coverage for hemodialysis based on a diagnosis of end-stage renal disease (ESRD) requires physicians in some states to manage chronic illness in this population using emergent-only hemodialysis. Emergent-only dialysis is expensive and burdensome for patients.OBJECTIVE To understand the illness experience of undocumented immigrants with ESRD who lack access to scheduled hemodialysis. DESIGN, SETTING, AND PARTICIPANTSA qualitative, semistructured, interview study was conducted in a Colorado safety-net hospital from July 1 to December 31, 2015, with 20 undocumented immigrants (hereinafter referred to as undocumented patients) with ESRD and no access to scheduled hemodialysis. Demographic information was collected from the participants' medical records. The interviews were audiorecorded, translated, and then transcribed verbatim. The interviews were analyzed using inductive qualitative theme analysis by 4 research team members from March 1 to June 30, 2016. MAIN OUTCOMES AND MEASURES Themes and subthemes from semistructured interviews.RESULTS All 20 undocumented patients included in the study (10 men and 10 women; mean [SD] age, 51.4 [13.8] years) had been in the United States for at least 5 years preceding their diagnosis with ESRD. They described the following 4 main themes: (1) a distressing symptom burden and unpredictable access to emergent-only hemodialysis, (2) death anxiety associated with weekly episodes of life-threatening illness, (3) family and social consequences of accommodating emergent-only hemodialysis, and (4) perceptions of the health care system.CONCLUSIONS AND ...

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This article proposes that knowledge of cultural expectations concerning ethical responses to unintentional harm can help students and physicians better to understand patients’ distress when physicians fail to disclose, apologise for, and make amends for harmful medical errors. While not universal, the Judeo-Christian traditions of confession, repentance, and forgiveness inform the cultural expectations of many individuals within secular western societies. Physicians’ professional obligations concerning truth telling reflect these expectations and are inclusive of the disclosure of medical error, while physicians may express a need for self-forgiveness after making errors and should be aware that patients may also rely upon forgiveness as a means of dealing with harm. The article recommends that learning how to disclose errors, apologise to injured patients, ensure that these patients’ needs are met, and confront the emotional dimensions of one’s own mistakes should be part of medical education and reinforced by the conduct of senior physicians.

Our survey of these PPC programs found that spiritual care was typically provided by staff chaplains, and our interviews indicated that chaplains appeared to be well-integrated members of these teams. Further research is needed to evaluate how well the spiritual needs of patients, families, and staff are being met, and the organizational factors that support the delivery of spiritual care in children's hospitals.