Provide resource nurses to support clinicians
Provide resource nurses to support clinicians
Palliative care education, support makes talk easier
Talking to patients and families about end-of-life care is not a task for which most physicians and other health care clinicians are prepared in their medical training. This is one reason that many don't bring up the subject and focus on curative treatment, even when it might be more appropriate to refer the patient to hospice.
Providing that training and developing a resource group of clinicians who can help with the difficult conversations has proven effective for two organizations.
Since 1998, the Catholic Healthcare Partners in Cincinnati has offered an educational program on palliative care and end-of-life care to clinicians throughout the health system, reports Cathy Follmer, RN, BSN, CHCE, CRNI, corporate director of continuum-of-care services. The curriculum includes topics such as pain management, advanced directives, and how to talk to people about their choices, she says. The curriculum was developed by Catholic Health Partners and is taught by palliative care coordinators. The program lasts for three weeks, she says. Everyone who completes the course, also referred to as the Angel Program, receives an Angel Certificate and is qualified to act as a resource for other staff members.
The participants in the Angel Program are all self-selected and must apply for acceptance to the program. "We limit the class to 140 people and we offer the class twice a year," she reports. People who have good communications skills, who have established good relationships with patients and physicians, and who are considered silent leaders within their departments are the type of applicants chosen for the class, she says. Follmer describes a silent leader as "a well-respected employee who is choosing to participate in the training because they believe it is a necessary skill to improve their ability to care for patients, not just because the program offers continuing education units."
The Visiting Nurse Service of New York (VNSNY) has tested a program that provides free consultants that help bridge the gap between home care and hospice. The first phase of the pilot program used an advanced practice nurse (APN) with an expertise in palliative care who worked with six out of the agency's 80 clinical teams. In addition to attending team meetings and offering advice to the home care teams when asked to help, the APN would accompany the home health nurse to the family's home to discuss palliative care and the hospice option. "Because families were offered the option, many chose to move to hospice care once they understood the benefits," says Dennis. As the home care teams became more familiar with the type of care offered by hospice and how it can improve the quality of life for patients at the end of their lives, more requests were made for consultations, she adds.
Because there was no feasible way to offer nurse practitioner support to all of the agency's home care teams, the second phase of the pilot program had the APNs train and mentor home health nurses to become the clinical resource nurses for the home care teams. "The nurses were chosen by their managers," says Karol Dibello, FNP, MS, BC, ACHPN, one of the two APNs for the program. Nurses did not volunteer and were chosen because the managers believed they were good nurses who would benefit from the additional training, she says. The first part of the course required 12 hours of didactic instruction on the basics of palliative care. The class is taught by the APNs and uses educational material developed by the palliative care team, Dibello says. "After the classroom work, we met with the nurses individually to continue training and offer support," she says. When necessary, the APNs would accompany the resource nurses on home visits, Dibello adds.
One of the benefits of training nurses already imbedded on the team was the fact that the nurses knew their community and the different cultures that might be represented, says Dibello. "The Queens area of New York is very culturally diverse, so the nurses need to understand the different beliefs each family might have about death," she explains. "There is also a great fear of opioids used for pain management and the threat of becoming addicted." By knowing the patients, families, and culture, the resource nurses could more quickly identify the correct approach to conversations about end-of-life, she says.
Results of the second phase of the pilot program still are being analyzed, so it is too early to compare the two phases directly, but it does appear that the first phase that used the nurse practitioner as a direct consultant to the team resulted in more referrals to hospice care, says Dennis. "We did see an increased awareness of palliative care and its benefits among all employees, and we'll continue our agencywide education on palliative care," she says. "We are also developing competencies on palliative care for all home health nurses to make sure they understand the principles."
Because the nurses in the VNSNY program did not volunteer, not all were fully prepared to conduct end-of-life conversations, admits Dibello. A self-selected group of nurses might have resulted in a greater use of hospice simply because they would have had an interest in the issue, she adds.Talking to patients and families about end-of-life care is not a task for which most physicians and other health care clinicians are prepared in their medical training. This is one reason that many don't bring up the subject and focus on curative treatment, even when it might be more appropriate to refer the patient to hospice.
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