An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.
Background Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care. Objective To implement and evaluate a palliative care professional development program for ICU bedside nurses. Methods From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses' ratings of their palliative care communication skills in surveys, and nurses' identification of palliative care needs during coaching rounds. Results Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P < .01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them. Conclusions Communication skills training workshops increased nurses' ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs. (American Journal of Critical Care. 2017; 26:361-371) by AACN on May 12, 2018 http://ajcc.aacnjournals.org/ Downloaded from P alliative care is a specialty and focus of care that aims to improve quality of care for patients who have serious and complex illnesses and their families. [1][2][3] Patients in intensive care units (ICUs) and their families have palliative care needs, including emotional support, management of pain and symptoms, and clinician-family communication to ensure that patients receive treatments that are consistent with their goals. [3][4][5][6][7][8][9][10][11][12][13] AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2017, Volume 26, No. 5 www.ajcconline.orgIn the ICU, palliative care is provided along with life-sustaining therapies and may be delivered by the ICU team (primary palliative care), a palliative care consult service (specialty palliative care), or both. 2,3,14 A number of barriers to integrating palliative care into the ICU have been identified, including inadequate training of clinicians and misperceptions that such treatment is the same as hospice, comfortfocused care, or end-of-life care. 3 Families, physicians, and nurses identify involvement of bedside nurses as a key factor in the quality of ICU palliative care. [15][16][17][18][19][20] Nurses' training and constancy at the bedside position them to identify palliative care needs, coordinate communication among families and an array of clinicians, and support and educate families. 15,16,19...
Our case describes the efforts of team members drawn from oncology, palliative care, supportive care, and primary care to assist a woman with advanced cancer in accepting care for her psychosocial distress, integrating prognostic information so that she could share in decisions about treatment planning, involving family in her care, and ultimately transitioning to hospice. Team members in our setting included a medical oncologist, oncology nurse practitioner, palliative care nurse practitioner, oncology social worker, and primary care physician. The core members were the patient and her sister. Our team grew organically as a result of patient need and, in doing so, operationalized an explicitly shared understanding of care priorities. We refer to this shared understanding as a shared mental model for care delivery, which enabled our team to jointly set priorities for care through a series of warm handoffs enabled by the team's close proximity within the same clinic. When care providers outside our integrated team became involved in the case, significant communication gaps exposed the difficulty in extending our shared mental model outside the integrated team framework, leading to inefficiencies in care. Integration of this shared understanding for care and close proximity of team members proved to be key components in facilitating treatment of our patient's burdensome cancer-related distress so that she could more effectively participate in treatment decision making that reflected her goals of care. CASE SUMMARYMartha was a 48-year-old woman with widely metastatic breast cancer who transferred care to our institution in June 2014. During the initial visit with the oncologist and oncology nurse practitioner (ONP), Martha seemed to be tolerating first-line treatment with minimal adverse effects, but she presented with a high degree of cancer-related emotional distress. The oncology team referred Martha via face-toface handoff to the embedded palliative care nurse practitioner (PCNP) who saw her in the oncology clinic on the same day and found concerning scores on the patient's Edmonton Symptom Assessment Survey for anxiety (score of 7 out of 10) and mild depression (score of 2 out of 10). Martha
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