Nurses Integral to Enhancing Palliative Care

When the usual medications do not alleviate the pain of a patient with multi-system failure, Tower 14 staff consult the Pain and Palliative Care Team at BWH.

“The Pain and Palliative Care team is very specific in their approach to a patient’s unique needs,” said Patricia Brita Rossi, MS, RN, nurse manager of Tower 14AB. “It’s not just about a medication, it’s about developing a plan of care for these patients while supporting their families at the same time.”

In addition to consultation around clinical care, this service also provides education to staff. “The members of the Pain and Palliative Care Team are clinical experts in their field, with a compassionate approach to patients and their families,” she said. “They come to team meetings and share their knowledge on how to better manage these patients.”

The focus on palliative care is increasing throughout the hospital, with nurses taking the lead to ensure the physical and emotional comfort of adult patients and neonates. In October, more than 60 nurses completed a two-day End of Life Nursing Education Consortium course at BWH, and many groups of nurses are initiating palliative care efforts on their units.

Nurses also are part of interdisciplinary group meetings to discuss how to improve palliative care, such as in the Connors Center, where a group is addressing the specific needs of families of infants whose life expectancy is limited. And the Pain and Palliative Care Team is working to ensure that palliative care is accessible to more patients throughout BWH.

“Patients can really benefit from the Pain and Palliative Care team stepping in,” said Phil Higgins, LICSW, one of the leaders of the University HealthSystem Consortium Palliative Care Initiative at BWH.

The initiative, which began this summer, aims to make palliative care more accessible to two groups of patients who can benefit from consultation: patients who have not been to the hospital recently and are here for an acute event, such as a heart attack or a brain hemorrhage; and patients who have been in the hospital at least twice in the past year and have a chronic or long-term illness, such as heart failure or COPD.

“With the acute patient population, the first goal always is to get them better and send them home as soon as possible. But there are some patients who will not survive the acute event and are appropriate for palliative care involvement,” Higgins said. “With the chronic population, illnesses with less predictable courses or trajectories are sometimes overlooked for palliative care consultation.”

The course of the disease for patients with terminal cancer, for example, can be more predictable than that of congestive heart failure, Higgins said. With either, patients may decline over time, but the trajectory for cancer patients may seem more obvious.

Eventually, the Pain and Palliative Care team will get a list of patients daily who meet the criteria for palliative care. “I will go to the units when the teams round on those patients,” Higgins said. “I’ll do a screening assessment that identifies patients appropriate for palliative care, and I will share this with the attending physician and ask if he or she would like a full consult. Depending on whether the need is based on pain and symptom management, psychosocial distress, clarification of goals of care, end-of-life decision-making or all of the above, the consult may be provided by the full interdisciplinary team or by one of the team social workers alone.”

Nurses can call Higgins for a consult on a patient they believe is appropriate for palliative care. “I’ve screened a number of patients so far at the request of nurses,” Higgins said. “After I screen the patient, I share my findings with the care team and the attending physician, who can approve a full consult. Just talking with nurses, social workers, attendings and housestaff puts this more on their radar and helps them keep it in mind.”

Higgins recently helped a care team facilitate a conversation with a patient’s family about palliative care. “The family didn’t feel their mother would want to keep getting interventions that ultimately could not save her,” he said. “They wanted to focus on comfort measures. Bringing the palliative care team into cases like this can help patients, families and providers to take a step back and refocus the direction of care in a way that better meets the patient’s needs and wishes.”

Palliative care patients with a cancer diagnosis may be transferred to the Intensive Palliative Care Unit (IPCU), a floating unit on Tower 4, 5, 6, 14 or 16, where they receive intensive pain and symptom management from an interdisciplinary team staffed primarily by palliative care physician assistants. Oncology patients may also be seen by the outpatient pain and palliative care clinic team which includes nurse practitioner Maureen Lynch.

Both oncology and non-oncology patients who are not on the IPCU service can receive expert palliative care intervention from the consult service, which includes nurse practitioner Jennifer Kales.

Palliative care is not just for adult patients. It’s emerging as an important focus for perinatal patients and their families in hospitals throughout the country.

In June, Ginny Silva, RNC, MSN, FNP-C, and Leslie Morette, BSN, RN, of the Center for Labor and Birth, and Gabriele Harrison, MS, RN, CPNP, IBCLC, and Allyson Litos, MSW, LCSW, of the NICU, received Mary Fay Enrichment awards for their proposals to develop a Perinatal Palliative Care Program for the CWN. The two awards will address establishing a palliative care program for families faced with a fetal diagnosis that is incompatible with life and for babies born with life limiting illnesses including congenital defects and chromosomal abnormalities. Plans include visiting other hospitals with established or emerging perinatal palliative care programs to assist in development of a similar program for the Connors Center.

In September, an interdisciplinary group in the Connors Center began meeting to define what a CWN perinatal palliative care program should encompass. The End of Life Oversight Committee, led by Angelleen Peters-Lewis PhD, RN, and Jennifer Cohen, MD, is working to identify care strategies that will give the best possible quality of life to the babies and their families as they deal with difficult choices and post partum course.

A strong foundation for a perinatal palliative care program already is in place at BWH. “We are very good at supporting parents through loss right now, but we want to coordinate our approach from Maternal Fetal Medicine to Labor and Delivery to the NICU and Post Partum,” Harrison said.

The group will examine the resources each department has now, and create standards, competencies, education, follow-up care and staff training. They will examine palliative care from ethical and spiritual standpoints, creating a cohesive program to support neonates and their families.

“We would like to help parents give a special meaning to the life their family has with their child,” Harrison said.