Palliative care team, case managers help

Approach can cut LOS, patient throughput

When Integris Baptist Medical Center in Oklahoma City began looking at implementing palliative care and end-of-life services, the case management department was the appropriate place to start, says Anita Bell, RN, MEd CHPN, palliative care coordinator at the 508-bed facility.

"There are so many similarities between palliative care and case management. Hospital case managers are constantly challenged to decrease the utilization of hospital resources and length of stay while maintaining quality care. Studies have shown that palliative care can decrease the cost of hospitalization and improve a patient's quality of life by advocating for care in the most appropriate setting," Bell says.

In addition to Bell, the palliative care team includes a chaplain, the medical director, a social worker, a pharmacist, and a nurse who does healing touch. "We've done some research, and healing touch has been able to show a decrease in pain and anxiety," Bell says.

The team is assisted by volunteers who handle data entry and make comfort care shawls that the palliative care team or nurse give to patients or family members, depending on the situation.

Case managers can see the big picture within the hospital and often are the first clinicians who identify patients who might benefit from palliative care services, Bell says. "Because of the case managers' focus on setting goals with the family, educating them, and looking at their discharge needs, they are instrumental in making sure we meet with patients and families who need palliative care services," she adds.

Palliative care and case management have mutual goals: decreasing length of stay and ensuring that patients receive the care they need at the right place in the continuum, Bell says. "Many times when patients have problems with pain or symptom management, they have a longer length of stay as the hospital staff try to get the problem under control. Palliative care helps with pain and symptom management, which can improve patient throughput and length of stay in the hospital," Bell says.

Case managers often call in the palliative care team for help in working with patients and family members to understand their options and to set goals of care for the patient, she adds. "The case managers will say to me that the physicians have talked to the patient and family, but they need more help understanding how ill the patient is and options for care. The palliative care team can go in with the doctor's permission and help educate the family and support them as they make choices," she says.

Patients who could benefit from a palliative care consultation often are identified during discharge planning rounds, says Suzanne Creekmore, RN, CCM, case manager for the med/surg intensive care unit and the intermediate care unit.

The discharge planning rounds in the ICU are attended by the case manager, the social worker, the nurse taking care of the patient, the chaplain, the ICU clinical director, the palliative care coordinator, and representatives from dietary, pharmacy, and other disciplines and departments if needed.

The team goes through each patient, one by one, starting with the diagnosis, the family support, and the goals for the day, along with individual details such as use of pain medication, ventilator length of stay, and psychosocial or family issues. The team discusses the plan of care and the discharge plan and looks at options if the patient isn't able to go home. For instance, if a patient has a stroke, is not responding, and isn't likely to recover, the team may call in Bell to help the family through the grieving process. Bell also may be called in if patients have a lot of pain that isn't being controlled with IV pain medication.

"We want to help the patients have better control of their pain for whatever time they have left, whether it's a matter of months or years. Some patients aren't ready for hospice and want to keep treatment going, but their quality of life will be better if their pain is under control," Creekmore says.

The case managers often call for a palliative care consultation for people who have chronic diseases, such as chronic obstructive pulmonary disorder, who are not necessarily at the end of the life but are getting worse. In those cases, Bell helps them get advance directives in place before they get really sick, Creekmore says. "We want to bring the palliative care team in as early as possible to help educate the patient and family members of their options for palliative care and comfort care. Our goal is to get the process started sooner so we can help the patient and family make the appropriate choices at the appropriate time," Creekmore says.

Bell gives the unit an extra set of eyes to help determine the best discharge plan for the patient, Creekmore says. "Her expertise can help us determine if it would be appropriate for us to discharge the patient to hospice or if he should stay in the hospital and receive hospice care here. She helps us determine how best to approach the family and comfort them," Creekmore says.

When a physician orders a palliative care consult, the case manager and the social worker on the unit accompany Bell as she visits with the patient and family members. But once Bell gets involved, Creekmore limits her visits with the family. "If too many people are involved in an emotional situation, it gets to be too much for the family. Once Anita takes over, I back off and go in and talk to the family every day," she says.

When she is called in on a consultation, Bell works with the chaplain, the social worker, the case manager, and physicians to look at pain and symptom management, develop goals of care, help the family do advance care planning, and to support the patient and family if they decide to withdraw lifesaving treatment, move to hospice care, or continue aggressive treatment. The team can call on a palliative care-certified physician who can meet with patients and help them understand their options.

"When people are in the ICU, so many things are being done for them. The case managers often hear that the patient never wanted that. They call the palliative care team in to talk with the family and clarify the goal of care and what the person wanted," Bell says.

In addition to Bell and the palliative care team, the hospital established the position of palliative care resource nurse on most of the units. The nurses have other nursing duties but have participated in training on palliative care, keep up with current literature on the subject, and know what resources are available. The palliative care resource nurses are an added level of expertise on the unit level and are able to identify patients who have more complex needs than what the regular staff can provide and who could benefit from a palliative care consultation, Bell says.

"When families are struggling with trying to make decisions, the palliative care resource nurse knows where to find the information they need. They have a higher training and competency than the rest of the staff. If the family needs more help, they may ask the doctor to ask for a palliative care consultation," she says.

Before establishing the palliative care program, the administration at Integris Baptist researched how the services are provided at other hospitals. The palliative care process was developed by a committee that included Bell, the case manager director at the time, the director of hospice, and the palliative care medical director, all of whom attended a conference to get ideas for the structures and processes that would work best at Integris Baptist. "We decided on an approach that embeds palliative care into our culture. We have palliative care resource nurses on most of the units who work along with the palliative care team," Bell says.

The team held in-service education sessions for the hospital's clinical staff and developed written material to educate the staff about palliative care. In the beginning of the program, Bell worked with the case management team to help them understand how palliative care could be helpful to their patients, so they could help inform other members of the treatment team about palliative care. She also taught them how to identify patients and family members who could benefit from a consultation.

The hospital established a palliative care steering committee to keep the process moving forward. The committee includes the palliative care coordinator, representatives from cardiovascular medicine service, the emergency department, the critical care and neurosciences services, chaplaincy services, pharmacy, social services, hospital medicine services, the ethics committee, and the cancer committee.

Before there was a formal process, most of the family consultations on palliative care and end-of-life issues were done by the social worker or the hospice team was called in, Creekmore says. "The palliative care team is a wonderful resource that can supplement communication and education provided by the treatment team and help the patients and family members understand their options," she says. "Heath care is so fragmented and patients and families are often overwhelmed with the disease process. All of us want to relieve suffering and improve the quality of life for our patients and family members." (For more information, contact Bell at