Palliative Care Fundamentals

Palliative Care

• Hospice is an interprofessional approach to end-of-life (EOL) care, focusing on aggressive pain and symptom control, spiritual and psychological care for the patient and family.
• Symptom management is prioritized over curative treatment.
• The disease is considered an end-stage condition progressing to death.

Palliative Care

• Palliative care focuses on maximizing quality of life during diagnosis, treatment, and life with serious illness.
• Unlike hospice, patients in palliative care can receive curative treatment.
• Early identification of physical, psychological, and spiritual problems is crucial.

HPNA Standards of Practice for Palliative Care Nurses

• Nurses provide age-appropriate, culturally, ethically, and spiritually sensitive care.
• Safe environments are maintained.
• Patients and families are educated about appropriate settings and treatment options.
• Care continuity and safe transitions are ensured.
• Care is coordinated across settings and among caregivers.
• Information is managed and confidentiality is protected.
• Communication is prompt and effective.

The Natural Course of Serious Illness

• Palliative care helps guide therapy at the initial diagnosis stage.
• Hospice becomes an option for care as the disease progresses to an end-stage condition.
• Hospice care and bereavement services are introduced when aggressive therapies are no longer effective and comfort care increases.

Prognostication

• Prognostication is based on laboratory findings and diagnostic test results.
• A meeting with the patient and family after gathering data is essential.
• Tools like the Palliative Performance Scale (PPS) and Karnofsky Scale can assess functional decline.

Hope

• Hopes for a cure, more time, pain relief, and a good death.

Triggers for Palliative Care Consult

• A positive response to the question "Would I be surprised if this patient died within 6 months to a year?"
• Patients requiring multifaceted care (e.g., ventilator support, feedings).
• Patients residing in long-term care facilities (nursing homes).
• The patient's age, cognitive impairment, current or past hospice enrollment, and lack of an advance care plan.

End of Life Nursing Education Consortium (ELNEC)

• Core curriculum includes nursing care at the end of life, pain management, symptom management, ethical/legal issues, cultural considerations, communication, loss/grief/bereavement, and the final hours.

National Consensus Project (NCP)

• A task force of organizations (AAHPM, CAPC, HPNA, NHPCO) focused on improving palliative care.

NCP Practice Domains

• Practice domains include:
  • Structure and Processes of Care,
  • Physical Aspects of Care,
  • Psychological/Psychiatric Aspects of Care,
  • Social Aspects of Care,
  • Spiritual/Religious Aspects of Care,
  • Cultural Aspects of Care,
  • Care of the Patient at the End of Life, and
  • Ethical and Legal Aspects of Care.

Palliative Care Model

• The family is the unit of care, and the patient defines the family unit.
• Nurses act as advocates for patients and families.
• Culture is considered an important aspect of patient/family care.
• Palliative care addresses special populations, including the vulnerable, prisoners, and substance abusers.
• Serious illness impacts all systems of care.
• Sensitivity to financial issues impacting patients' quality of life are crucial.
• Palliative care extends beyond cancer and AIDS to all life-threatening illnesses.
• Interprofessional care is essential for high-quality palliative care.

Unrelieved Pain

• Unrelieved pain exacerbates distress, hinders coping, increases vulnerability, and interferes with daily activities (eating, sleeping, thinking, interacting).
• It is correlated with fatigue in cancer patients.

Critical Thinking Question

• An appropriate question for a palliative care nurse to ask a patient regarding pain is: "Is your pain interfering with your ability to sleep?"

Benefits of Palliative Care

• Relief of suffering, optimization of function, promotion of comfort, fostering of hope, genuine care coordination, and preparation for hospice.

Suffering

• Suffering is a state of severe distress associated with events threatening a person's well-being and is a central focus of palliative care.

Strategies for Family Caregivers

• Strategies include setting realistic goals, having difficult discussions, finding help, and negotiating expectations.

Barriers and Challenges

• Barriers and challenges include lack of understanding by healthcare professionals and consumers, limited numbers of trained professionals, and communication difficulties regarding palliative care services and payment.

Areas of Expertise for Hospice and Palliative Care Nurses

• Areas of expertise include clinical judgment, advocacy and ethics, professionalism, collaboration, systems thinking, cultural competence, facilitation of learning, and communication.

Certification

• Generalist level certifications include Certified Hospice and Palliative Nurse (CHPN), and Palliative Nurse Administrator (CHPA).
• Advanced level certifications include Advanced Certified Hospice and Palliative Nurse (ACHPN).
• Certifications are available through Institutional (e.g., TJC); or Voluntary certification.
• Voluntary certification is aimed at high-quality palliative care.

Quality Assessment and Improvement

• Efforts are focused on multiple areas of quality improvement, including patient-centered pain management within 48 hours of admission, avoidance of unwanted hospitalizations/CPR, and patient safety.
• NHPCO leads quality initiatives.
• CAPC plays a role in quality assessment and improvement initiatives.

Concerns

• Ethical concerns include advance planning, double effect, palliative sedation, and medically futile care.
• Legal concerns include the right to refuse treatment and landmark cases (e.g., Karen Ann Quinlan, Nancy Cruzan).