This is the second part of a two-part article on the aims and practice of palliative care and its essential philosophy and concepts. Originally published by the Vermont Nurse Connection, DailyNurse thanks the ANA-VT and the authors for graciously allowing us to re-post this. Click here to read Part One.
Originally published in Vermont Nurse Connection (the official newsletter of ANA-VT), July 2020
There is a growing body of evidence showing that palliative care results in an improved quality of life for people with serious illnesses. It’s also been shown to result in higher levels of patient satisfaction and improved outcomes at the end of life. While it’s not hard to understand why a palliative approach might improve someone’s quality of life or lead to greater satisfaction with care, it’s also been found that the costs associated with someone’s care usually decrease as a result of palliative involvement. This is likely due to palliative care’s emphasis on uncovering a person’s goals and values and then building a care plan to which these goals are central.
For example, the standard treatment offered by our healthcare system is aggressive, disease-directed care right up until the moment of death, which is fine, but is not what everyone wants. Collaborating with patients and offering care based on their values (instead of the system’s), especially when those values mean something other than intensive hospital-based care, inevitably results in lower costs. But one of the more unexpected benefits of palliative care turns out to be longer life: which has been found in a few studies in both the cancer and heart failure populations.
We hope that the two case studies presented below will illustrate a few palliative care interventions as well as highlight the role that RNs and LNAs can have in treating suffering. We hope this article has given you a better sense of what palliative care has to offer, and also how RNs and LNAs, because of their scope of practice, are in a unique and privileged place to provide this care.
Case 1, “Charlie”: Discussing the Future with a Heart Failure Patient
Charlie calls the heart failure clinic with a question about his symptoms. As the clinic nurse you have seen Charlie get all the best possible treatment over the past three years, including a biventricular pacemaker with a defibrillator. You are worried now because despite everyone’s best efforts he is beginning to have more shortness of breath. You talk to his cardiologist to determine next steps, and then phone Charlie back with instructions to increase his torsemide and monitor his symptoms over the next few days. He shares that he’s worried: does this mean that his heart failure is getting worse? You resist the urge to “fix his feelings,” and instead say, “I am worried too, we are going to do our best to help support you and try to improve your symptoms.”
Charlie calls back two days later to say how much better he feels. This is good news, but you decide to deepen the conversation, saying, “I would really like to learn more about you so that we have a better sense of how to care for you going forward. Could I ask you a few questions?“ Charlie welcomes the chance to talk, so you continue: “At this time in your life, what things are most important to you? When you think about your future, what are you hoping for? And what are you most worried about?” Charlie gives you a wealth of information, and you document your conversation in the chart.
The next week Charlie comes in for his routine clinic appointment. He lets you know that the conversation you had with him was very helpful and relieved some of his stress and worry. He asks if there are other things he should be thinking about? You steer the conversation to what’s known as “advance planning”: “Have you completed an advance directive? If you were so sick that you couldn’t make your own medical decisions who would make them for you? Finally, you offer to help him complete his advance directive (this is a document identifying a health care agent as well as what forms of treatment you would/would not want).
Case 2, “Alison”: Providing Comfort and Support for a Stage IV Cancer Patient
Alison is being admitted to the cancer floor with abdominal pain related to stage IV ovarian cancer. Sarah is her nurse for the evening shift. Alison’s pain requires regular use of her PRN dose just to keep it under control. She also shares that she is not sure that she wants to continue chemotherapy. Sarah calls the attending and recommends a palliative care consult. “Alison is using frequent PRN doses and I feel her symptoms could be better controlled. She is struggling with what her care should look like going forward.” The attending physician is convinced and orders a palliative care consultation.
Later that evening Alison’s LNA, Beth, finds her sitting up in the chair crying. Alison shares that she just got off the phone with her teenage son, and she is worried about him. Beth asks Alison if it would be OK if she just sat with her. Alison agrees and they sit in silence for a while until Alison starts sharing about how hard this has been. Beth offers a supportive statement, “I cannot imagine how hard this must be for you.” Beth listens as Alison describes how wonderful her son is and how he has been caring for her. Beth says, “You must be very proud of him… How do you hope he’ll remember you?”
Over the course of Alison’s hospitalization, she is started on scheduled doses of long-acting morphine, and her pain decreases. She rarely requires PRN doses. However, then at a family meeting her oncologist shares that there are no more cancer treatments available. Alison asks Sarah’s opinion about whether or not she should go home on hospice. Sarah assesses Alison’s understanding, asking her what she knows about hospice. Alison answers that she is not sure, but that her doctors said since there are no more cancer treatments she should “consider hospice.” Sarah describes hospice as an extra layer of support to help people make the most of the time they have left, and when they are closer to dying, to ensure they have a peaceful death. Alison starts to tear up and asks, “Does this mean I am dying now?”
In response, Sarah gently asks Alison to say more about what she is feeling. Alison goes on to share that she hopes she has more time to spend with her son, and to be able to see a few more of his tennis matches. Sarah responds, “I hope that you are able to do this too.” Alison goes on to tell you more about her son and her attempts to ask him about her illness. Sarah shares that hospice can also provide support for having these conversations and will also be there to provide bereavement support for Alison’s family after her death. After Sarah spends time addressing Alison’s concerns while also responding to her emotions, Alison seems more at peace.
Resources
Serious Illness Conversation Guide
CAPC (Center to Advance Palliative Care)
Hospice & Palliative Nurses Association HPNA
American Academy of Hospice and Palliative Medicine (AAHPM)
Vital Talk: National organization committed to building clinicians’ serious illness conversation skills. Vermont has its own version called TalkVermont.
Five Wishes: “To help start and guide family conversations about care in times of serious illness”
The Conversation Project: A “starter kit” to “provide a shared understanding of what matters most to you and your loved ones”
