“A young lad stands!” exclaimed an individual living with dementia, as they translated the first line of their favorite song, “Tumbalalaika” during a music therapy session. In that moment, one with such limited speech prior to engaging in the music, was able to not only sing along, but translate a lyric from Yiddish to English.

Music Therapy and Memory Connection

As a budding music therapy student at Berklee College of Music, this became a formative experience for Hannah Righter, now the Director of Arts at Connecticut Hospice. To see firsthand the impact music can have on reconnecting individuals to the present moment – so much so that they are able to engage in ways they could otherwise not due to disease progression – was truly eye-opening.

Since then, there have been numerous studies conducted supporting the global neurological engagement that takes place even while passively listening to music (Toader et al., 2023). When combined with the strong emotional connection many have with music, this results in the ability to use music to bypass damaged areas of the brain. This is paramount for individuals diagnosed with dementia, who, through music, can connect with their loved ones in meaningful ways.

The responses evoked by the music might not always be as grandiose as regaining the ability to translate from one language to another. Sometimes, it may be as seemingly subtle as tapping to the beat or maintaining eye contact. Yet, each of these moments can be just as profound as the next. It’s these interactions that highlight the power of the arts in fostering connection, even when verbal communication becomes more difficult.

Integrating the Arts into Hospice and Palliative Care

The story touched upon above is just one of many that speak to the impact the arts can have on patients receiving hospice and palliative care. At Connecticut Hospice, the integration of the arts is woven into the fabric of their care approach, ensuring that every patient and their loved ones have the opportunity to experience art, music, and other forms of creative expression. Whether it’s actively engaging in music and creating a piece of art or passively listening and watching, the arts can play a key role in fostering connection, comfort, and peace.

A Legacy of the Arts in End-of-Life Care

Connecticut Hospice can proudly celebrate its legacy as the first hospice founded in America, but its remarkable history extends beyond that. In 1979, they became pioneers in the provision of excellent end-of-life care once yet again by incorporating the arts into their interdisciplinary team approach, establishing one of the first Arts programs in hospice care. Since then, the Arts Program at Connecticut Hospice has only continued to grow, expanding its reach through a diverse team of art and music therapists, volunteers, students, and a highly skilled portrait artist.

Honoring Creative Arts Therapies Week

With Creative Arts Therapies Week falling in the third week of March, it's the perfect opportunity to recognize the invaluable contributions of Connecticut Hospice’s art and music therapists, who work closely with patients and their families both at their inpatient facility and in the community. Their therapists are dedicated to enhancing quality of life for as long as life is lived. Through the power of art and music, they address goals that extend beyond artistic or musical achievements, focusing on emotional, mental, and spiritual well-being. 

The Lasting Impact of Art and Music Therapy

Whether it's using patient-preferred music to increase relaxation, collaborating with an art therapist to create a meaningful gift for a loved one, or helping patients express themselves by composing a song with a music therapist, their work promotes connection and healing. Hospice’s art and music therapists work to create a space where individuals can confront, explore, and articulate complex emotions while also finding creative ways to honor and celebrate a life lived. Ultimately, one of the most rewarding aspects of their work is helping provide patients and families with the chance to create lasting, positive memories, even in the most challenging of times.

Discover how the arts bring comfort, connection, and healing to hospice patients. Explore Connecticut Hospice’s Arts Program to see how you can support or get involved.

Opioids and Their Role in Pain Management

Opioids are commonly used to relieve pain and shortness of breath in seriously ill people and those at the end of life. While highly effective, these drugs also cause side effects that may limit their use.

Managing Opioid Side Effects

Addiction – also called opioid use disorder – is believed by many to inevitably result from prolonged use of opioids, but this concern is unmerited when these important medications are used appropriately by experienced practitioners.

Common opioid side effects such as sedation, constipation, and nausea usually wear off within a few days of use and can be countered with other medications. For example:

• Methylphenidate (Ritalin) can reverse opioid-induced sedation.
• Opioid rotation (switching from one opioid to another) may help with delirium, restlessness, agitation, and confusion while maintaining pain relief.

Non-Opioid Pain Medications

Other, less potent but effective pain medications include:

Acetaminophen (Tylenol, APAP, etc.)

• Effective for mild to moderate pain, such as:
  • Osteoarthritis
  • Muscle strain or sprain
  • Tension headaches
• Precautions:
  • Maximum dose: 1000 mg (two extra-strength tablets) four times a day.
  • Overdose risk: Can cause life-threatening liver damage at higher doses.
  • Often found in combination with over-the-counter medications, requiring careful ingredient checks.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Includes ibuprofen and naproxen.
• Used for pain related to inflammation, such as:
  • Rheumatoid arthritis
  • Joint inflammation
• Precautions:
  • Must be taken per manufacturer-recommended doses.
  • Short-term use is advised to avoid stomach ulcers, bleeding, and kidney damage.

Adjuvant Medications for Pain Relief

What Are Adjuvants?

Adjuvant medications are drugs that are not primarily designed for pain relief but can help manage pain by either enhancing the effects of traditional pain medications or providing their own analgesic properties. They are especially useful for neuropathic pain, which often does not respond well to opioids alone.

How Do Adjuvants Work?

Adjuvants include medications that either:

• Have analgesic properties on their own (e.g., methadone, gabapentin, pregabalin, ketamine).
• Enhance the effects of other pain medications to improve symptom control.

Types of Adjuvant Medications

Tricyclic Antidepressants (TCAs)

Used for:

• Trigeminal neuralgia (facial nerve pain)
• Radiculopathy (sciatica, herniated disc pain)
• Phantom limb pain
• Spinal cord injury pain
• Post-stroke pain syndrome
• Temporomandibular (TMJ) joint pain
• Chemotherapy-induced neuropathic pain

Other Antidepressants (SNRIs)

Used for:

• Diabetic neuropathy
• Trigeminal neuralgia
• Post-herpetic neuropathy
• Chronic pain and fibromyalgia
• Migraine

Used for:

Anticonvulsants

• Neuropathic pain (including post-herpetic neuralgia)
• Fibromyalgia
• Phantom limb pain
• Multiple sclerosis-related pain
• Post-stroke pain

Muscle Relaxants

Used for:

• Pain associated with muscle spasms or contractures
• Common muscle relaxants:
  • Tizanidine
  • Cyclobenzaprine

Topical Medications

Used for:

• Localized pain relief, such as swollen, painful joints
• Common options:
  • Capsaicin
  • Lidocaine patches

Ketamine

• A potent tranquilizer and sedative.
• Used for:
  • Refractory pain (pain that does not respond to other treatments).
• Typically administered intravenously under medical supervision but can also be given intranasally or via other routes.

Methadone

• While typically associated with opioid use disorder treatment, methadone can also be highly effective for pain relief.
• Particularly useful for:
  • Patients on very high opioid doses
  • Neuropathic pain

Considerations for Safe Use

While it is beyond the scope of this blog, all these agents have side effects and toxicities. Anyone using them should:

• Be informed of possible side effects by their physician.
• Carefully read printed medication guidelines provided with the drug.

Addressing Underlying Conditions That Can Worsen Pain

Pain is often worsened by underlying conditions, such as:

• Depression and anxiety
• Insomnia and poor sleep
• Post-Traumatic Stress Disorder (PTSD)
• Bipolar disorder
• Schizophrenia and other psychoses

Managing these conditions alongside pain treatment can significantly improve overall well-being.

Compassionate Pain Relief and Symptom Control

At Connecticut Hospice, we specialize in expert pain and symptom management for patients facing serious illness and end-of-life care. Our dedicated team understands that effective pain relief is essential to maintaining comfort and dignity.

Whether through outpatient care or our licensed inpatient hospital, we provide the highest level of personalized pain relief and symptom control to enhance quality of life.

• Outpatient Palliative and Hospice Care – "Stand by Me" Program: Expert medical care, symptom management, and pain relief provided at our clinic, in your home, or within assisted living facilities.
• Inpatient Hospice & Palliative Care: Our one-of-a-kind inpatient hospital offers 24/7 advanced pain management, including infused medications and rapid dose adjustments, for those whose symptoms cannot be controlled at home.

Compassionate, expert pain relief is our priority. Let us help you find comfort and dignity at every stage of care.

Call us today at 203-315-7543 to learn more or schedule an appointment.

As we age, our needs evolve. For seniors, these changes may include complex health conditions, mobility issues, or memory impairment, making it harder to manage daily activities. Navigating these challenges can be overwhelming for both seniors and their families. This is where Geriatric Care Management services come into play—offering essential support to help seniors lead healthier, safer, and more fulfilling lives. 

What is Geriatric Care Management? 

Geriatric Care Management is a specialized service that provides personalized care coordination for older adults. Geriatric Care Managers (GCMs), also known as aging life care professionals, are trained to assess the needs of seniors and create a comprehensive care plan tailored to their unique situations. This service helps families ensure that their loved ones are receiving proper care while improving their quality of life. 

Key Services Provided by Geriatric Care Managers 

1. Comprehensive Assessment of Needs - One of the first steps in geriatric care management is a thorough assessment. The GCM evaluates the senior’s physical, emotional, and mental health, as well as their social and environmental factors. This assessment provides a clear picture of the challenges the senior is facing, such as chronic health conditions, mobility limitations, or cognitive decline. 

2. Personalized Care Plan - Based on the assessment; a tailored care plan is developed. This plan addresses specific needs, including medical care, daily activities, medication management, and assistance with tasks like bathing, dressing, and eating. The goal is to create a plan that supports the senior’s independence while ensuring safety and comfort. 

3. Coordination of Care - Seniors often require services from a variety of healthcare professionals, such as physicians, physical therapists, home health aides, and specialists. A GCM ensures that these professionals work together seamlessly, coordinating appointments, medications, and treatments to prevent gaps in care. 

4. Monitoring and Advocacy - GCMs not only monitor the senior’s progress but also act as advocates to ensure that their needs are met. They help with navigating complex healthcare systems, such as Medicare and Medicaid, and offer advice on selecting appropriate care providers. They also ensure that seniors’ rights are upheld and that their voices are heard in decision-making processes. 

5. Crisis Management and Emergency Planning - Life is unpredictable, and emergencies can happen at any time. GCMs are skilled in responding to crises, whether it’s a sudden health decline, a fall, or an unexpected hospital stay. They help manage these situations by creating emergency plans and ensuring that all necessary resources are in place. 

6. Family Support and Guidance - Caring for an aging loved one can be emotionally and physically taxing for family members. GCMs offer families the support they need, providing education, guidance, and reassurance. They help families understand the best options for care and make informed decisions, relieving the stress that often comes with caregiving responsibilities. 

The Benefits of Geriatric Care Management 

1. Improved Quality of Life - With the assistance of a GCM, seniors can receive the right care and services to enhance their overall well-being. Whether it’s access to social activities, improved medical care, or better day-to-day support, the goal is to ensure that seniors can live their lives to the fullest. 

2. Peace of Mind for Families - Caring for an aging loved one from a distance or while managing other responsibilities can be overwhelming. GCMs provide families with the peace of mind that their loved one is in good hands, receiving appropriate care and attention. Families can rest assured knowing that professionals are managing the care plan and overseeing their loved one’s well-being. 

3. Prevention of Hospital Readmissions - GCMs play a critical role in ensuring that seniors follow their prescribed treatments and medications, which helps to prevent avoidable hospital readmissions. Through regular monitoring and support, they catch potential issues before they escalate, keeping seniors healthier and avoiding unnecessary medical interventions. 

4. Cost-Effective Care - While it may seem that hiring a geriatric care manager is an added expense, in many cases, it can actually save money in the long term. GCMs can help families identify more affordable care options, prevent costly hospital stays, and reduce the likelihood of long-term health complications, all of which contribute to better financial outcomes. 

When to Consider Geriatric Care Management Services 

Geriatric Care Management services are beneficial in various situations. Some examples include: 

• Seniors experiencing multiple health issues or chronic conditions 

• Families who are caring for an aging loved one but need professional assistance 

• Seniors who are struggling with memory loss or cognitive decline 

• Families living at a distance and seeking local support for their loved ones 

• Individuals transitioning from a hospital stay to home care or assisted living 

If you notice that your loved one’s health is declining or that daily activities are becoming increasingly difficult to manage, it might be time to consider the support of a Geriatric Care Manager. 

In conclusion, Geriatric Care Management is a valuable service that provides older adults with the support they need to age with dignity, comfort, and independence. By partnering with a trained professional, seniors and their families can ensure that the right care is delivered at the right time. Whether it's coordinating medical care, managing emergencies, or simply offering guidance, a geriatric care manager can make all the difference in enhancing the lives of aging adults and their families. 

If you're considering Geriatric Care Management services, JDT Care Solutions, a new program under The Connecticut Hospice umbrella of services, offers a free 15-minute professional consult to determine how a geriatric care manager can best support you or a loved one’s unique needs. 

Please contact Lorraine Castronova, MSW, LCSW

JDT Care Solutions, Geriatric Care Manager

Email: [email protected]

Office: 203 315 7692

Cell: 203 500 2850

Many people who are considering hospice care ask the question: “Can I continue to see my doctor after I enroll in hospice?” This guide will answer that question, and clarify Medicare’s seemingly complicated rules in hopes of promoting your ongoing involvement with the doctor who has served you so well. 

Medicare Hospice Benefit and Physician Options

This guide focuses on Medicare, which is the insurer for most people in hospice -- the Medicare Hospice Benefit (MHB). If your hospice care is not covered by the MHB, you may want to contact your insurer directly to find out the rules.

Usually, the doctor that people want to continue to see is the specialist who treated them for the condition that led to hospice enrollment, for example, a cardiologist for people with heart disease or an oncologist for people with cancer.

Yes, You Can Keep Your Doctor, but There Are Some Limitations

It is possible for your specialty doctor to remain involved in your care, provided he or she agrees to act as your “hospice primary attending.” This is the doctor who works with the hospice interdisciplinary team (IDT) to guide care – mostly by providing medication orders over the phone to the hospice nurse who comes to your home. 

Hospice Primary Attending Physician

If you want your specialty doctor to remain involved in your care, ask him or her to agree to be your hospice primary attending – but remember that most of his or her involvement will be in directing your care over the phone with your hospice team, not in seeing you in the office. They are also unlikely to order blood tests, x-rays, or CT scans for you, as those tests will not contribute to your comfort after you are no longer being treated medically. (And you may be billed for them if they are ordered.)

Notify Your Physician of Your Hospice Enrollment

You can still see your regular – non-hospice – primary care doctor while you are in hospice, or a specialty doctor that you see for a condition unrelated to hospice. For example, if you are enrolled in hospice for lung cancer but also suffer from rheumatoid arthritis. It is important to understand, however, that the Medicare Hospice Benefit will not pay for primary or specialty care, or medications, for services unrelated to your hospice diagnosis – the condition that led to your enrolling in hospice, like heart disease or cancer. However, Medicare Part B (which pays for office visits) and Medicare Part D (which covers prescription medications) will usually still pay for these services – though you should notify the non-hospice specialist and primary care doctor that you are enrolled in hospice and covered by the MHB before making an appointment.

You Can Always Choose a Hospice Doctor

If you decide not to ask the specialty doctor who provided care for the condition that led to your enrolling in hospice to act as your hospice primary attending, or if he or she chooses not to do so, your hospice care will be assumed by the hospice medical director or another physician employed by or contracted with hospice. For example, if your oncologist declines to be your hospice primary attending, the hospice MD becomes your doctor. If you still decide to see your oncologist, the MHB will not cover the visit, and you may be billed for it.

REMEMBER! The following are covered under the Medicare Hospice Benefit:

• Durable medical equipment (e.g., hospital bed)
• Ambulance transportation
• Medications related to your hospice diagnosis
• Nursing visits
• Social work visits
• Chaplain visits
• Volunteer visits needed for your care

In summary, your care may continue to be directed by your specialty doctor if he or she agrees to be your hospice primary attending, though that will probably not involve office visits, blood tests, x-rays, or CT scans. If your doctor declines that role, your care will be overseen by a hospice doctor. Doctor visits and medications that are unrelated to your hospice diagnosis are not covered by the Medicare Hospice Benefit, but are generally still covered by Medicare Parts B and D. 

Feel free to call the admissions department at The Connecticut Hospice, Inc., at 203-315-7540 if you have questions.

Connecticut Hospice recently held a ribbon-cutting ceremony to celebrate the opening of its Palliative Care Clinic. This celebration occurred shortly after the official launch of its Palliative Care Program, Stand by Me. In addition to meeting with our clinicians at their newly launched waterfront clinic, services can also be provided at skilled nursing homes and long-term care facilities.

Stand by Me Palliative Care Program

The Stand by Me palliative care service is a physician and APRN consultative program for the treatment of discomfort, symptoms, and stress caused by a serious illness. Palliative care works with primary medical practitioners to attain treatment goals, prevent or ease suffering, and improve quality of life. It gives patients a chance to live better, have better physical functioning, and decrease depression and anxiety.

What is Palliative Care?

The goal of Palliative Care is to improve the quality of life for patients being treated for serious illness. It is appropriate for all stages of treatment, starting at diagnosis. The focus is on relieving complex physical, psychological, social, and/or spiritual problems related to life-limiting or irreversible illness. It includes counseling on disease management to empower patients to better understand their illness and its treatment so they can choose the care best suited to their unique needs.

Palliative Care Symptom Management Includes:

• Pain
• Shortness of breath
• Fatigue
• Constipation
• Nausea
• Loss of Appetite
• Irregular or lack of sleep
• Side effects from treatment

Palliative Support You Can Depend On

Palliative care is available to you at anytime during the course of your illness. You can meet with a palliative specialist as little or more often as needed. Palliative care does not mean you are dying, it is about living better, healthier, and being as comfortable as possible. This all leads to a better quality of life and better engagement with loved ones. Very often, people under palliative care continue treatment of their disease and stabilize and graduate from the service. Palliative care is about living long and well!

Learn more about our Outpatient Palliative Care Services

Relief Without Delay

You should not have to endure unnecessary suffering from symptoms of disease or treatment. We respond promptly to calls for assistance, offering 24/7 support. We understand the urgency of your needs and can swiftly schedule in-person visits with our full-time Advanced Practice Registered Nurse, ensuring expert symptom management and counseling on disease management options within days, not months.

Call today to schedule an appointment: 203-315-7540

What's the difference between Palliative care and Hospice Care?

Click the links below to learn more about Palliative care vs. Hospice care.

Compassionate Care: Hospice vs. Palliative Care Insights

Palliative Care vs. Hospice Care—What You Need to Know

Mother of a Cancer Patient Authors a Guide to Palliative Care

Hospice care is a specialized form of healthcare that focuses on enhancing the quality of life for individuals with terminal illnesses. The goal is to provide comfort, support, and dignity during the end-of-life journey. However, the use of medications, particularly benzodiazepines, have been both a blessing and a controversy in end-of-life care. In this blog post, we will explore the role of benzodiazepines in hospice care, the benefits they offer, potential drawbacks, and the ethical considerations surrounding their use. 

Understanding Benzodiazepines

Benzodiazepines are a class of sedative drugs that act on the central nervous system. They are commonly prescribed to alleviate symptoms such as anxiety, insomnia, and seizures. These medications produce a calming and sedative effect. Examples of benzodiazepines include diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax). While these medications can be highly effective in managing certain conditions, their use in hospice care requires careful consideration.

Benefits of Benzodiazepines in Hospice Care:

1. Anxiety and Agitation Management: One of the primary benefits of benzodiazepines in hospice care is their ability to manage anxiety and agitation. Patients facing terminal illnesses often experience heightened stress and restlessness. Benzodiazepines can provide relief, promoting a sense of calm and comfort in the final stages of life. 

2. Insomnia Relief: Terminal illnesses can disrupt sleep patterns, leading to insomnia. Benzodiazepines may be prescribed to help patients sleep more soundly, contributing to an improved overall quality of life during their remaining time. 

3. Seizure Control: For individuals with terminal conditions that may involve seizures, benzodiazepines can be crucial in controlling and preventing these episodes. This can significantly enhance the patient's comfort and reduce distress. 

4. Symptom Management in Respiratory Distress: In cases where respiratory distress is a prominent symptom, benzodiazepines can help relax the respiratory muscles, making breathing more comfortable for the patient. 

Potential Benzodiazepine Drawbacks and Concerns:

1. Sedation and Cognitive Impairment: A common concern with benzodiazepine use in hospice care is the potential for sedation and cognitive impairment. While these effects can be beneficial in managing symptoms like anxiety, sedation may hinder the patient's ability to interact with loved ones or communicate effectively. 

2. Risk of Withdrawal and Tolerance: Prolonged use of benzodiazepines can lead to tolerance, in which a medication becomes less effective over time, making higher doses necessary for the desired effect. Symptoms such as increased anxiety, jitteriness, or -- in rare circumstances -- seizure can result from abruptly stopping these medications, but is rarely a concern in hospice patients, in whom their cessation is unusual. 

3. Respiratory Depression: Benzodiazepines, particularly in combination with other medications, can contribute to respiratory depression, a possible concern in patients who already have compromised respiratory function. Expert, judicious use of these medications – essential for the relief of anxiety and air hunger in patients at the end of life– by experienced hospice physicians mitigates this risk. 

4. Communication Challenges: Side effects such as sedation and cognitive impairment that may be unexpected by the families and loved ones of hospice patients can create misunderstanding between healthcare providers, patients, and their families. Clear information as to each patients  goals of care and the use of these medications becomes vital to ensure that the patient's wishes and concerns are understood and addressed. 

Other Benzodiazepines Considerations:

The use of benzodiazepines in hospice care requires thoughtful reflection. Key considerations include: 

• Patient Autonomy: Respecting the autonomy of the patient is paramount. Healthcare providers must engage in open and honest discussions with patients, involving them in decisions about their care and the use of medications. 

• Balancing Symptom Relief and Quality of Life: Striking a balance between providing symptom relief and maintaining the patient's quality of life is paramount to hospice care. The experienced hospice professionals at Connecticut Hospice are expert in weighing the benefits and risks of benzodiazepine use, and considering the individual needs and preferences of each patient. 

• Informed Consent: Informed consent is crucial in hospice care, including education about the benefits and risks of benzodiazepine use. Patients and their families should be well-informed to make decisions aligned with their values and goals. 

• Regular Reassessment: Regular reassessment of the patient's condition is essential to ensure that the benefits of benzodiazepine therapy continue to outweigh potential risks. Adjustments to the treatment plan may be necessary based on the evolving needs and circumstances of the patient. 

Benzodiazepines in Palliative Sedation:

Palliative sedation is a carefully regulated and monitored medical intervention that is employed when other forms of symptom management have proven ineffective. It is typically reserved for patients experiencing severe distress, refractory symptoms, or existential suffering that cannot be alleviated through conventional means. Palliative sedation aims to balance the relief of symptoms with the preservation of patient comfort and dignity. Benzodiazepines, a class of sedative drugs, are frequently employed in palliative sedation due to their effectiveness in promoting a peaceful and comfortable experience for patients nearing end of life. 

The use of benzodiazepines for palliative sedation in hospice care is a complex but widely ethically accepted practice. These medications offer effective symptom control and rapid onset of sedation, and their use requires careful consideration of individual patient needs, open communication, and adherence to ethical practice – long a core principal of patient care at Connecticut Hospice.  The goal of hospice physicians who employ palliative sedation is always the enhancement of patient comfort and dignity during the final stages of life. By embracing a patient/family-centered, multidisciplinary approach, healthcare professionals can provide compassionate care that honors the values and preferences of those under their charge, ensuring a peaceful and dignified journey toward the end of life. 

Best Benzodiazepine Practices and Guidelines:

• Individualized Care Plans: Tailored Approaches: Recognizing that each patient's experience is unique, hospice professionals should develop individualized care plans, considering the specific symptoms, medical history, and preferences of the patient. 

• Multidisciplinary Collaboration: Team Approach: A multidisciplinary approach involving physicians, nurses, social workers, and other healthcare professionals is essential. Regular team discussions can help assess the ongoing need for benzodiazepines and adjust treatment plans accordingly. 

• Regular Reassessment: Ongoing Evaluation: Given the dynamic nature of hospice care, continuous reassessment of the patient's condition and response to benzodiazepines is crucial. Adjustments to medication regimens should be made based on the evolving needs of the individual. 

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Common Benzodiazepines:

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Benzodiazepines in Hospice Care Conclusion:

The use of benzodiazepines in hospice care requires careful consideration of medical, ethical, and patient-centered factors by experienced physicians and nurses. These medications offer valuable benefits in managing symptoms associated with terminal illnesses; patients and families may be assured that the healthcare providers at Connecticut Hospice expertly navigate all potential concerns associated with their use. Open communication, informed consent, and regular reassessment are key components of a comprehensive approach to benzodiazepine use in hospice care, ensuring that the patient's final journey is characterized by comfort, dignity, and respect for their autonomy.