Nurse Practitioners and Palliative Care: What to Know and How to Help - NPACE (2022)

Improved quality of life, patient goal-focused care, and decreased health care spending are all benefits of palliative care. Patients who need palliative care often have chronic conditions that can be terminal or non-terminal, such as neurological trauma, cancer, lung disease, Alzheimer’s, Amyotrophic lateral sclerosis, Crohn’s Disease, and many more. Due to the current COVID-19 pandemic, palliative care patients are even more vulnerable because of their underlying medical conditions and potential immune-deficiency. Therefore, they should be guided by healthcare practitioners on how to safely address their health concerns, and access healthcare if needed.

With the advancement of technology and pharmaceuticals, the number of seriously ill people in need of palliative care is growing. Unfortunately, the demand for services is greater than the supply of palliative caregivers.

Many primary caregivers believe that integrated primary and palliative care is a potential solution. So, what gap between the shortage of palliative care specialists and the demand for palliative care services could NPs fill? What are the skills that comprise primary palliative care and are they already a part of every NP’s practice? Finally, what are additional learning opportunities for NPs to build expertise in primary palliative care?

Components of Palliative Care

In a palliative care facility, the palliative care team consists of doctors and nurse practitioners that work together to help patients meet their life goals. They help relieve symptoms that disrupt the patient’s ability to live their life by adjusting pain medications and diet, help patients understand their diagnosis and treatment options, clarify treatment goals, and coordinate care with other doctors. Most importantly, they work with patients to help them make medical decisions that best align with the patient’s life goals and philosophy.

Palliative care in the United States has primary, secondary, and tertiary levels. Primary palliative care encompasses the basic skills of palliative care and thus can be practiced by nurse practitioners. Secondary palliative care is practiced by clinicians who provide patients with more complex diseases with a consultative approach and specialist knowledge. Finally, tertiary palliative care is practiced at cutting-edge medical research and academic facilities. This is where field advancements are being made.

What Primary Palliative Care Roles Could NPs Take Over?

Nurse practitioners can be found in nearly any medical field or healthcare setting, from major urban hospitals to rural community clinics. For this reason, nurse practitioners are well-positioned to provide thorough symptom assessment and management and initiate and guide conversations around advance care planning.

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Symptom Management

NPs can have a huge impact on palliative care patients by helping them with symptom management. Based on a patient’s symptoms, the NP should be able to identify how the patient’s disease/condition is progressing and how this affects the patient’s overall goals.

When it comes to symptom management, an NP is able to examine patients, evaluate their symptoms and conditions, and manage their condition. They are competent to explain different therapies and treatments, as well as the risks and benefits that are present.

But physical pain and discomfort is not the only thing an NP will have to address. Spiritual or emotional distress is equally as likely to be present in palliative patients. To provide the best care possible, NPs should respectfully ask patients about their religious or spiritual beliefs and how to incorporate them into their care plan. This may not be easy; it requires nuanced interpersonal communication and empathy.

Advance Care Planning

Nurse practitioners may also be involved in patient’s advance care planning with their MD and family. When assisting with advance care planning, NPs aid in identifying medical decision-makers for the patient, as well as acknowledging their health care wishes.

An NP working on advanced care planning needs to clearly and openly discuss symptoms, diagnoses, and prognosis for patients and possibly their families. A patient’s illness may be complicated and very serious, so it is important to have these conversations in order to best serve their health care wishes. Ideally, these conversations should initially take place in the outpatient setting so patients and their families can think over these complicated and important decisions.

During advance care planning conversations, be ready to discuss disease progression, potential therapies or interventions, and prognosis. These conversations may not be easy or comfortable, but facilitating open communication about these topics is a learnable skill. There are online resources, such as VitaTalk to build expertise, both with written material and with video demonstrations.

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Other Roles for NPs in Primary Palliative Care

Palliative care is a complex, lengthy process. While NPs can primarily assist in providing symptom management and advance care planning, they could also fill other roles in palliative care in the future.

Transitioning to Hospice Care

When treating patients undergoing palliative care, it is important to discuss hospice care. If NPs believe their patient will succumb to their disease within 6 months, they should have a conversation with the patient about a hospice referral. Although NPs cannot currently sign the certification required to transfer a patient to hospice care, they can inform patients about options and what to expect. If the patient prefers, their Nurse Practitioner can also stay involved in a consultative role after the patient is admitted to hospice.

Discussing Code Status

In palliative care, discussing code status means talking to the patient about what goals are important to them and what they envision about their quality of life.

Nurse practitioners may have to consult with treating specialists to find out what therapy options are available for their patients. Even if the specialist has already discussed this with the patient, NPs can reinforce important information with the patient later. A consistent message from care providers can greatly contribute to decreasing patient confusion and making them feel more empowered. NPs can offer their patients more information about risks and benefits of treatment, as well as expected outcomes. nurse practitioners should always make sure their patients know they can ask questions and go over what was discussed.

Billing for Advance Care Planning

In the last few years, changes have been made so that NPs can be reimbursed by Medicare Part B and Medicaid for palliative care. According to Kathleen Neuendorf and Mellar Davis, “When face-to-face time includes discussion and documentation on prognosis, treatment choices, and advance directives, this qualifies as advance care planning” and can be billed as such (Wheeler, M.S, 2014). nurse practitioners do not need to fill out relevant legal forms, but they should always use the right codes and adhere to time requirements. Use CPT Code 99497 for the first 30 minutes of conversation CPT 99498for each following 30 minutes of conversation.

Refer When Needed

Nurse practitioners are often not palliative care experts. When faced with difficult, complicated symptoms, delicate family situations, or contentious care decisions, it may be best to consult a palliative care specialist.

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Nurse practitioners Fill the Gaps in Primary Palliative Care

Palliative care provides patients with a life-threatening or life-limiting illness the extra support they need to successfully manage their illness and sustain quality of life. New research shows that nurse practitioners are uniquely suited to filling in the existing gaps in palliative care by:

  • Assessing medical conditions
  • Managing symptoms
  • Consulting with specialist
  • Offering psychosocial support to patients and families
  • Educating patients and families about treatment and prognosis
  • Providing ongoing care
  • Advocating for patient’s rights and wishes

Clearly, nurse practitioners are a necessary part of primary palliative care and their involvement in the process helps enhanced care for seriously ill patients.

Resources:

Colins M. Carmel. “The nurse practitioner role is ideally suited for palliative care practice: A

qualitative descriptive study”. Canadian Oncology Nursing Journal published online Feb 1, 2008, doi: 10.5737/2368807629149

Loscalzo, Matthew J. “Palliative Care: An Historical Perspective.” Hematology, vol. 2008, no. 1,

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Jan. 2008, pp. 465-465, doi: 0.1182/asheducation-2008.1.465

Nowels, D., et al. “Perspectives of Primary Care Providers Toward Palliative Care for Their

Patients.”, The Journal of the American Board of Family Medicine, vol. 29, no.6, Jan. 2016, pp. 748-758, doi: 10.3122/jabfm.2016.06.160054

Parish, M., “Weaving Palliative Care into Primary Care: A Guide for Community Health Centers”,

California Healthcare Foundation, https://www.chcf.org/wp-content/uploads/2017/12/PDF-WeavingPalliativeCarePrimaryCare.pdf

Wheeler, Mary S. “Primary Palliative Care for Every Nurse Practitioner”.The Journal for Nurse

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Practitioners, vol. 12, issue 10, Dec. 2016, pp. 647 -653,https://www.npjournal.org/article/S1555-4155(16)30503-7/fulltext

“Palliative Care Considerations for Patients with Cardiovascular Disease Under COVID-19.”American College of Cardiology, 9 Apr. 2020, https://www.acc.org/latest-in- cardiology/articles/2020/04/09/12/42/palliative-care-considerations-for-patients-with-cardiovascular-disease-under-coronavirus-disease-2019-covid-19

“Palliative vs. Hospice Care – Frequently Asked Questions.”Get Palliative Care, https://getpalliativecare.org/whatis/faq/

FAQs

What are the nurse's responsibilities when caring for a patient in palliative care? ›

Palliative care nurses provide an integrative and multidisciplinary treatment approach that helps patients maintain physical, mental, and emotional health. They take the time to understand the needs of each patient in order to provide a customized treatment plan that provides lasting relief.

What are the 3 main goals of palliative care? ›

The goals are:
  • Relieve pain and other symptoms.
  • Address your emotional and spiritual concerns, and those of your caregivers.
  • Coordinate your care.
  • Improve your quality of life during your illness.
22 Aug 2021

How can I help palliative care? ›

End of life: Managing mental and emotional needs
  1. Provide physical contact. Try holding hands or a gentle massage.
  2. Set a comforting mood. Some people prefer quiet moments with less people. ...
  3. Play music at a low volume. This can help with relaxation and lessen pain.
  4. Involve the dying person. ...
  5. Be present.

What is the most important role of the nurse caring for someone who is under palliative sedation and why? ›

During the course of palliative sedation, the nurse must involve and support the family but also ensure that the patient's room is peaceful and quiet. The family may, if they wish and feel it is appropriate, be involved in caring for the patient.

How do nurses provide palliative care? ›

Skilled and empathetic communication is essential in providing excellent palliative care. Nurses are trained in communication skills that allow them to discuss prognosis, goals of care, advance care planning clinical options, and medical decisions with patients and caregivers.

What are the 5 principles of palliative care? ›

The principles of palliative care
  • Affirms life and regards dying as a normal process.
  • Neither hastens nor postpones death.
  • Provides relief from pain and other distressing symptoms.
  • Integrates the psychological and spiritual aspects of care.
  • Offers a support system to help patients live as actively as possible until death.
24 May 2021

What are the 5 aims of palliative care? ›

What are the goals of palliative care?
  • Pain management. Most terminal illnesses cause significant physical pain. ...
  • Treating symptoms. ...
  • Counselling and therapy. ...
  • Assistance with living. ...
  • Patient mobility. ...
  • Connection. ...
  • Understanding. ...
  • Help for families and loved ones.
8 Nov 2021

What are the 12 principles of a good death? ›

It identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with the health care provider and “other.”

What type of approach do we need in palliative care? ›

Palliative care uses a team approach to support patients and their caregivers. This includes addressing practical needs and providing bereavement counselling. It offers a support system to help patients live as actively as possible until death.

What do you say to someone who is on palliative care? ›

Examples
  1. “Thank you for all the days you've made brighter just by being you. ...
  2. “Thinking of the good life you've lived, the great times we've shared, and feeling so grateful for you.”
  3. “You've been such an important part of my life, and for that, I'll always be grateful.”
30 Apr 2020

What is a key aspect of the work that palliative care doctors do? ›

Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family.

How does palliative care help the elderly? ›

In addition to improving quality of life and helping with symptoms, palliative care can help patients understand their choices for medical treatment. The organized services available through palliative care may be helpful to any older person having a lot of general discomfort and disability very late in life.

What drugs are used in palliative sedation? ›

The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering.

Why is pain management important in palliative care? ›

Pain management is a key part of end of life and palliative care. If pain is well managed, quality of life will be better. The person is likely to sleep better and have more energy during the day. If they feel less pain, they can be more active, which also reduces the risk of complications.

What is palliative care sedation? ›

Listen to pronunciation. (PA-lee-uh-tiv seh-DAY-shun) The use of special drugs called sedatives to relieve extreme suffering by making a patient calm, unaware, or unconscious. This may be done for patients who have symptoms that cannot be controlled with other treatment.

How would the nurse support the dying individual? ›

The role of the nurse during the active dying phase is to support the patient and family by educating them on what they might expect to happen during this time, addressing their questions and concerns honestly, being an active listener, and providing emotional support and guidance.

What's the difference between end of life and palliative care? ›

Palliative care is available when you first learn you have a life-limiting (terminal) illness. You might be able to receive palliative care while you are still receiving other therapies to treat your condition. End of life care is a form of palliative care you receive when you're close to the end of life.

Why do doctors recommend palliative care? ›

It provides relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a specially-trained team who work together with your other doctors to provide an extra layer of support.

What is the difference between hospice and palliative care? ›

Hospice is comfort care without curative intent; the patient no longer has curative options or has chosen not to pursue treatment because the side effects outweigh the benefits. Palliative care is comfort care with or without curative intent.

What is the aim of palliative care? ›

Palliative care is an approach to treatment which aims to: Improve the quality of life of patients and their families facing the problem of life-threatening illness. Prevent and relieve suffering. Identify, assess and treat pain and other problems, physical, psychosocial and spiritual.

What are the major challenges in palliative care? ›

These challenges include physical pain, depression, a variety of intense emotions, the loss of dignity, hopelessness, and the seemingly mundane tasks that need to be addressed at the end of life. An understanding of the dying patient's experience should help clinicians improve their care of the terminally ill.

What are three roles of the PSW when caring for a person with palliative care needs? ›

Personal Support Workers (PSWs) – Support workers provide personal care, assist with household tasks, and provide company for your loved one when you can't be there.

What are the roles and responsibilities of a palliative care? ›

1 Palliative care focuses primarily on anticipating, preventing, diagnosing, and treating symptoms experienced by patients with a serious or life-threatening illness and helping patients and their families make medically important decisions.

What are the responsibilities of a hospice nurse? ›

What Does a Hospice Nurse Do?
  • Monitoring and documenting patient vital signs. An important part of hospice care is regularly checking on the health of a patient. ...
  • Administering medications. ...
  • Managing symptoms and pain. ...
  • Helping during crisis situations. ...
  • Psychosocial support. ...
  • Spiritual support. ...
  • Educating family caregivers.

What are the responsibilities of a nurse when death occurs? ›

The role of the nurse during the active dying phase is to support the patient and family by educating them on what they might expect to happen during this time, addressing their questions and concerns honestly, being an active listener, and providing emotional support and guidance.

What is the role of personal care worker in palliative care? ›

Palliative care is provided by a team of healthcare professionals with a range of skills to help you manage your life-limiting illness. Your palliative care team works together to meet your physical, psychological, social, spiritual and cultural needs and also helps your family and carers.

What are the 5 principles of palliative care? ›

The principles of palliative care
  • Affirms life and regards dying as a normal process.
  • Neither hastens nor postpones death.
  • Provides relief from pain and other distressing symptoms.
  • Integrates the psychological and spiritual aspects of care.
  • Offers a support system to help patients live as actively as possible until death.
24 May 2021

What are the 5 aims of palliative care? ›

What are the goals of palliative care?
  • Pain management. Most terminal illnesses cause significant physical pain. ...
  • Treating symptoms. ...
  • Counselling and therapy. ...
  • Assistance with living. ...
  • Patient mobility. ...
  • Connection. ...
  • Understanding. ...
  • Help for families and loved ones.
8 Nov 2021

Why is palliative care important to nursing? ›

Palliative care is important because it gives patients an option for pain and symptom management and higher quality of life while still pursuing curative measures. When a patient is seriously ill, they understand the value of each day.

Which is the most important hospice nursing role? ›

The role of a case manager is one of the most direct, hands-on nursing roles in a hospice organization. Hospice case managers oversee the direction and coordination of a patient's care — and the care provided for their caregivers and family — throughout their time in hospice.

What's the difference between hospice and palliative care? ›

Palliative Care vs Hospice Care

Hospice is comfort care without curative intent; the patient no longer has curative options or has chosen not to pursue treatment because the side effects outweigh the benefits. Palliative care is comfort care with or without curative intent.

What should a nurse do immediately before death? ›

The nurse should always treat the body with dignity and respect. Position the body in supine position with anatomical alignment. Close eyes and mouth if open. Remove any clothing, jewelry, and personal items and bag for family pick-up.

What is the last breath before death called? ›

Agonal breathing or agonal gasps are the last reflexes of the dying brain. They are generally viewed as a sign of death, and can happen after the heart has stopped beating.

What is one of the most important interventions for a nurse to implement when caring for a patient who is terminally ill? ›

What is one of the most important interventions for a nurse to implement when caring for a patient who is terminally ill? The simple presence of someone provides support and comfort.

What are three roles of the PSW when caring for a person with palliative care needs? ›

Personal Support Workers (PSWs) – Support workers provide personal care, assist with household tasks, and provide company for your loved one when you can't be there.

What qualifications do you need to do palliative care? ›

A degree in medicine, nursing or dentistry or a 2:1 degree in life sciences or social sciences. You must also have experience of working in palliative care or an associated area, eg clinical or social care research.

Why is a multidisciplinary approach important in palliative care? ›

Multidisciplinary team meetings are a recognised component of palliative care as well as in a range of other care settings (eg, cancer). The meetings provide an opportunity to coordinate multiple clinical and social services that might be relevant for complex patient needs.

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