Palliative Care for Advanced Practice Nurses

Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. ¹  Palliative care is defined in the Institute of Medicine (IOM) ²  report Dying in America as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness and their families. Palliative care is part of the continuum of care from the time of diagnosis of a serious illness to care that extends to hospice and end-of-life care. Patients may enter intensive care as a result of an acute illness or injury or as a result of an exacerbation of a chronic illness. Increasingly, technology is used to extend life and delay death. Despite the advances in health care and technology, each of us will die, and although 1 in 4 patients dies in a hospital, most people want to die at home. ³ 

Because so many people are living with various stages of advanced illness in which the course of the injury or illness cannot be easily predicted, health care providers must know patient preferences for care. Preferences should be reviewed often, as they may change as disease progresses. All patients with serious life-limiting illnesses and injuries, not just those who are actively dying, need effective symptom management. Unrelieved symptoms are distressing to patients and families. Seriously ill patients and their families need support from an interdisciplinary team of providers, including nursing, medicine, palliative care experts, social work, clergy, and grief counselors.

Despite the growing number of palliative care programs in hospitals and communities, the number of specialty-trained clinicians is still quite small. Advanced practice registered nurses, nurses, and other clinicians need to be well educated in meeting the palliative needs of their patients and families. The IOM report The Future of Nursing: Leading Change, Advancing Health sees application of a palliative care model as consistent to core nursing values in providing care to patients and families, regardless of age, culture, socioeconomic status, or diagnosis. ⁴  All practitioners need education and training focused on palliative and end-of-life care, which is of utmost importance in high-intensity situations that occur in the acute care setting where the stakes are high. Developing expertise in critical skills such as symptom management, communication, managing conflict, and estimating prognosis is vitally important. Many medical and nursing programs are now integrating palliative and end-of-life courses in their curricula. Training programs such as the End-of-Life Nursing Education Consortium by the City of Hope and the American Association of Colleges of Nursing prepare nurses to provide palliative and end-of-life care. ⁵ 

The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. ¹  However, despite this knowledge, palliative care often is not initiated until patients are in the terminal stages of health. Advance care planning should take place at the time of diagnosis of serious illness. The IOM report on palliative care supports early advance care planning and stresses the important role that clinicians have in honoring patient preferences for treatment near the end of life. ²  In addition, several professional organizations have put forth position statements and guidelines about the importance of advance care planning in serious illness, including, for example, the American Heart Association/American College of Cardiology joint position statement for both heart failure ⁶  and for stroke, ⁷  the American Thoracic Society guidelines for chronic obstructive pulmonary disease, ⁸  the Renal Physician Association guideline in end-stage renal disease, ⁹  and the Hospice and Palliative Nurses Association position statement on advanced care planning. ¹⁰  The overarching theme of these guidelines is to have the discussion and review it at critical junctures such as hospitalization or exacerbation of illness or on an annual basis, with the utmost importance placed on honoring the wishes of patients. Despite these guidelines, widespread adoption is slow, and often clinicians do not have this conversation when things are going well, which means that APNs who work in the inpatient setting must become skilled in having crucial conversations with patients and families. This symposium is a starting point.

We have assembled a group of articles that discuss the practical skills for discussing goals of care and breaking bad news and discussing prognosis. We know that these discussions are difficult and at times do not go well. So, we have included an article on how to address and manage conflict. Ethical dilemmas related to palliative and end-of-life care occur in the critical care setting, so we have included an article on common ethical dilemmas that includes suggestions for management. We also have included an article on symptom management that gives some concrete advice on integration of palliative symptom management as the patient approaches the end of life. We encourage you to use this symposium as a starting point to improving your skill level in providing palliative care. Our patients and their families deserve it.