Professional Documents
Culture Documents
Susan Bohnenkamp, MA, RN, ACNS-BC, CCM, is Clinical Nurse Specialist, University
difficult for medical-surgical nurses
and can be provided to patients and While certain aspects of eligibility 3. Psychological and psychiatric
families at any point along the ill- criteria may differ among individ- aspects
ness trajectory, not just in a ual hospices, enrollment in all 4. Social aspects
patient’s final weeks or days. The Medicare-certified hospices requires 5. Spiritual and existential aspects
flexibility of palliative care can be a physician to certify the patient is 6. Cultural aspects
especially beneficial to patients suf- terminally ill and has a prognosis of 7. Care at the EOL
fering from conditions such as heart 6 months or less if the disease runs 8. Ethical and legal aspects
failure (HF) and chronic obstructive its normal course. Specific criteria Medical-surgical nurses can assess
pulmonary disease, for which prog- also exist for most major illnesses patients’ needs through the lens of
nosis is difficult to determine and (e.g., cancer, HF, HIV/AIDs, demen- each domain and match those needs
unpredictable exacerbations are tia) and hospices can be consulted with available resources. Under-
common (Holmes & Scullion, 2015; for informational patient visits to standing the domains of palliative
Kheirbek et al., 2013). Importantly, help determine eligibility. Many care provides nurses with a useful,
a growing body of compelling evi- hospices also require patients to concrete framework to care for
dence demonstrates early palliative forego life-prolonging therapies, for patients coping with life-limiting ill-
care improves health and survival which the burden outweighs the ness.
outcomes (Adelson et al., 2017). benefit and can contribute to symp-
tom distress (e.g., total parental
Hospice nutrition for patients with metasta- Structure and Process of
Hospice is defined as, “a service tic cancer, blood transfusions for Care
delivery system that provides pallia- patients with end-stage HF). How- Medical-surgical units housing
tive care for patients who have a ever, individual therapies often are patients with serious illness should
limited life expectancy and require considered on a case-by-case basis. have a structure in place for offering
comprehensive biomedical, psy- and providing palliative care servic-
chosocial, and spiritual support as es. Structure formality varies
they enter the terminal stage of an NCPQPC Domains of depending on location and avail-
illness or condition” (Center to Palliative Care able resources; however, as illness
Advance Palliative Care [CAPC], In 2001, the National Consensus progresses, communication among
n.d., p. iii). CAPC suggested one Project established eight essential patient, family, provider, and team
way to conceptualize hospice is as domains of palliative care to provide should increase (Agency for
an intensification of palliative care benchmarks and guidance for clini- Healthcare Research and Quality
specifically designed for a patient’s cians and institutions regarding [AHRQ)], 2013). When and how to
final months. In the United States, delivery of quality palliative care introduce conversations regarding
Congress established hospice as a (American Association of Colleges of palliative care should be delineated
Medicare benefit in 1986 and set Nursing, 2016; NCPQPC, 2013): clearly, and taught to nurses and
the benchmark eligibility criteria 1. Structure and process other team members.
for patient enrollment in hospice. 2. Physical aspects
TABLE 2.
Internet Palliative Care Resources for the Medical-Surgical Nurse
Interprofessional Palliative should find an accessible training In this type of model, basic pallia-
Care and Team Training program that is relevant to the tive care training must be mandato-
Palliative care teams are interpro- needs of their units (see Table 2). ry for all acute care providers (Quill
fessional, ideally including physi- Physicians and nurses may be & Abernathy, 2013).
cians, nurses, social workers, and trained as palliative care specialists,
When to Initiate
chaplains at a minimum. Larger or be general practice providers who Conversations about
teams may include trained volun- implement a basic palliative care Palliative Care
teers, psychologists, and therapists. approach (primary palliative care) in
Important questions should be
Medical-surgical nurses and other their patient care. Economic and
addressed when identifying a pat-
providers benefit from palliative resource constraints mean hiring
ient who may benefit from pallia-
care training focused on symptom palliative care specialists is not tive care. For example, is the patient
assessment and management, care always feasible. One cost-effective experiencing disease progression,
of the actively dying patient, discus- alternative can be development of a especially with functional decline?
sion of advance directives and how partnership between palliative care Is the patient experiencing pain or
to lead family meetings, and effec- specialists outside the hospital and other symptoms not responding to
tive use of resources in the hospital generalists inside the hospital (Quill optimal medical treatment? Is there
and community (Sheldon, Dahlin, & Abernathy, 2013). As part of a a need for advance care planning
Maingi, & Sanchez, 2017). Team coordinated model of care, general- and clarification of goals of care
building and communication train- ists can deliver primary palliative (NCPQPC, 2013)? If a patient meets
ing should be ongoing so team care by beginning conversations any of the three criteria, the nurse
members can collaborate and coor- related to goals of care and address- should communicate with the pri-
dinate advanced care planning ing basic symptom management mary provider about the potential
meetings with patients and families needs. For particularly difficult or for enhancing palliative care sup-
(Wittenberg, Ferrell, Goldsmith, refractory symptoms, a palliative port. Another method to identify
Ragan, & Paice, 2016). Nurse leaders care specialist referral can be made. patients for palliative care is to use
TABLE 3.
Helpful Palliative Care Communication Phrases for the Medical-Surgical Nurse
challenge that frequently occurs at care patients include delirium, agi- iety and depression. The idea of
the EOL (Kirshbaum, Olson, Pong- tation, anxiety, and depression depression as a normal part of the
thavornkamol & Graffigna, 2013). (NCPQPC, 2013). Delirium occurs terminal illness process contributes
Fatigue can be managed by address- in 30%-50% of all patients in pallia- to its under-treatment. Symptoms
ing potential underlying problems tive care, with agitation occurring include depressed mood, feelings of
such as sleep patterns, pain, nutri- 13%-46% of the time (Hey, Hosker, worthlessness, fatigue, sleep distur-
tion and exercise, and depression. Ward, Kite, & Speechley, 2015). bances, change in appetite, and loss
Fatigue may not need aggressive Nonpharmacological management of memory. These symptoms can
intervention. Pharmacological man- includes oxygen, fluid and elec- overlap with others that normally
agement of fatigue is controversial, trolyte management, frequent reori- occur with terminal illness and
and more research is needed to entation to environment, exercise, medication use, making diagnosis
determine what is most effective for pain management, and bladder and difficult. Nurses can simply ask,
patients at the EOL (Mucke et al., bowel management. Pharmacologic “Are you depressed?” as this ques-
2015). Constipation is common in treatment may include antipsy- tion has been found to be an
persons receiving opioids for pain chotics, sedatives, psychostimu- extremely effective way to identify
management in advanced disease. lants, and cholinesterase inhibitors; depression. Antidepressant therapy
Nursing assessment should involve each comes with risks, including takes time, usually several weeks, to
questioning patients on the frequen- further interference with a patient’s reach peak effect, so it may be nec-
cy and quality of bowel movements, cognition and paradoxically wors- essary to add a psychostimulant
with appropriate interventions as ening agitation or delirium (Hey et such as methylphenidate to im-
needed. al., 2015). Treatment choice should prove mood more quickly (Jordan
be individualized and adjusted to et al., 2015). Prompt referral to
meet patient and family needs. social work, psychology, psychiatry,
Psychosocial and Psychological distress commonly and/or a religious minister/spiritual
Psychiatric Aspects of Care occurs at the EOL and can be mag- support may be helpful. Reflective
Common psychosocial and psy- nified in the presence of pre-exist- listening and focusing the conversa-
chiatric symptoms for palliative ing mental illness, particularly anx- tion on the patient’s goals of care
http://www.cancer.org/treatment/finding
andpayingfortreatment/understanding
Nurses can provide the patient with needs, medical-surgical nurses have
financialandlegalmatters/advancedirect
as much autonomy as possible at the opportunity to enhance quality
ives/advance-directives-types-of-
the EOL by remembering their roles patient outcomes.
advance-health-care-directives
American Nurses Association. (2017). Short
as patient advocates. When advo-
REFERENCES definitions of ethical principles and theo-
cating on behalf of a patient’s wish-
Abu-El-Noor, N. (2016). ICU nurses’ percep- ries: Familiar words, what do they mean?
es is not possible, they should not
hesitate to call the ethics team for tions and practice of spiritual care at the Silver Spring, MD: Author.
end of life: Implications for policy change. Broadhurst, K., & Harrington, A. (2016). A the-
The Online Journal of Issues in Nursing, matic literature review: The importance
help (Nelson et al., 2013).
21(1). doi:10.3912/OJIN.Vol21No01PPT05 of providing spiritual care for end-of-life
Adelson, K., Paris, J., Horton, J.R., Her- patients who have experienced tran-
nandez-Tellez, L., Ricks, D., Morrison, scendence phenomena. American
Conclusion
S., & Smith, C.B. (2017). Standardized Journal of Hospice and Palliative Care,
criteria for palliative care consultation on 33(9), 881-893.
Medical-surgical nurses with a
a solid tumor oncology service reduces Center to Advance Palliative Care (CAPC).
foundational understanding of pri-
downstream healthcare use. Journal of (n.d.). Policies and tools for hospital pal-
mary palliative care principles and a
genuine desire to advocate for Oncology Practice, 13(5), e431-e440. liative care programs. Retrieved from
doi:10.1200/JOP.2016.016808 https://media.capc.org/filer_public/88/06/
Agency for Healthcare Research and Quality 8806cedd-f78a-4d14-a90e-aca688147
patients and families can achieve
(AHRQ). (2013). Palliative care for adults: a18/nqfcrosswalk.pdf
optimal care for patients with life-
Guideline summary. Rockville, MD: Clabots, S. (2012). Strategies to help initiate
limiting disease. The NCPQPC (2013)
Author. and maintain the end-of-life discussion
Aldridge, M.D., Epstein, A.J., Brody, A.A., Lee, with patients and family members.
provides a framework for delivery of
E.J., Cherlin, E., & Bradley, E.H. (2016). MEDSURG Nursing, 21(4), 197-204.
high-quality, effective palliative care
The impact of reported hospice preferred Glare, P.A., & Chow, K. (2015). Validation of a
to alleviate patient suffering. Stra-
practices on hospital utilization at the end simple screening tool for identifying
tegies to improve distress and symp-
of life. Medical Care, 54(7), 657-663. unmet palliative care needs in patients
American Association of Colleges of Nursing. with cancer. Journal of Oncology Prac-
tom assessment can be integrated