Discussion - Clinical Practice Issues in Hospice and Palliative Care

[MissKristenRN]

Good afternoon fellow colleagues and students!

I am a registered nurse currently enrolled in a DNP program. I have been practicing as a RN for 5 years in acute care and also in hospice and palliative care. I have worked in a hospice inpatient facility, pediatric home care, and adult home care. I currently work in acute care setting on a med-surg tele floor per diem. I also work full-time in hospice home care as an on-call RN.

I am writing for a few reasons today.

First, I am curious if there are any other HPNA members here? I have been a member of HPNA for 4 years. (Anyone going to the conference in San Diego next month? I am very much looking forward to it!) It appears the HPNA website has been revamped. I remember there being a discussion board community but I cannot locate it on the website now. I was hoping to post a topic about clinical practice issues in hospice and palliative care in hopes of receiving insight from my fellows about current practice issues impacting your care today.

This brings me to my next inquiry. Are there any clinical practice issues relating to hospice and palliative care that you see especially pertinent to addressing to better your practice and outcomes? How is evidence based practice implemented in your hospice and palliative nursing?

When I think of clinical practice issues in hospice and palliative care a few things come to mind. First, I think about the period of time between diagnosis and referral to palliative care services, or if the referral is very late in the trajectory of illness, it may be a direct hospice referral. I think about the process by which palliative care services are implemented in the hospital where I also work and how those referrals are conducted and the impact it has on patient and family outcomes. The things that come to mind for me are more big picture concept analyses.

Can you think of any point-of-care clinical practice issues in hospice and palliative care? I have a much easier time identifying clinical practice issues in the acute care setting that have EBP solutions. Think Joint Commission fundamentals, CAUTI, CLABSI, sepsis, pressure injuries, etc. It is must more difficult for me to identify hospice specific practice issues. Pressure injuries could be one.

Anyways, thank you in advance! Have a blessed day!

[db2xs]

Hi there. I have been a HPNA member for eight years and currently serve on the Executive Board of my local chapter. I am an NP.

On 2/11/2020 at 9:42 AM, MissKristenRN said:

(Anyone going to the conference in San Diego next month? I am very much looking forward to it!)

I am not going. Have fun!

On 2/11/2020 at 9:42 AM, MissKristenRN said:

It appears the HPNA website has been revamped. I remember there being a discussion board community but I cannot locate it on the website now. I was hoping to post a topic about clinical practice issues in hospice and palliative care in hopes of receiving insight from my fellows about current practice issues impacting your care today.

There may have been a discussion board but I was always a member of various SIG boards. Maybe that's what you're thinking of?

On 2/11/2020 at 9:42 AM, MissKristenRN said:

This brings me to my next inquiry. Are there any clinical practice issues relating to hospice and palliative care that you see especially pertinent to addressing to better your practice and outcomes? How is evidence based practice implemented in your hospice and palliative nursing?

Yes, for sure. Clinicians are still not exactly using EBP in hospice and palliative care. Simple things like medication management/pill burden/inappropriateness is one of them (think statins, my personal pet peeve docusate for constipation, bisphosphonates, etc.) in limited prognosis patients.

On 2/11/2020 at 9:42 AM, MissKristenRN said:

Can you think of any point-of-care clinical practice issues in hospice and palliative care? I have a much easier time identifying clinical practice issues in the acute care setting that have EBP solutions. Think Joint Commission fundamentals, CAUTI, CLABSI, sepsis, pressure injuries, etc. It is must more difficult for me to identify hospice specific practice issues. Pressure injuries could be one.

CAUTI, CLABSI, sepsis are definitely more inpatient issues but pressure injuries are definitely issues both in and out patient. Same with falls. Possibly UTI? Many of my patients end up with UTIs.

Other big issues to consider: Depression is huge in outpatient hospice/palliative care (not that it's not big in inpatient either), but I see too often patients depressed at the end of life not being treated adequately for it. Adequate pain mgmt is *huge.* Caregiver burnout is massive.

In hospice, we're not going to allow certain medical events to occur, e.g., a UTI, especially if it affects their comfort. It's about focusing on comfort and quality of life. Some of my dementia patients, they hallucinate but they're in their own zone and it's not causing them any distress so are we going to force them to take anti-psychotics? No. In my opinion, the clinical issues are more qualitative than quantitative.

Someone else can chime in! ?

[Daisy4RN]

A few observations from working inpatient hospice/palliative and HH.

Transitions can be very difficult for pt and/or family. More education would benefit. For example, pt tx from ICU to med-surg for hospice/end of life care, or pt tx from hospital to home. Education re: next steps, what to expect etc.

Evidenced based practice and JC fundamentals/recommendations dont always work for everyone (news flash I know). Newer nurses need education re: alternative methods for personalized care (ie work arounds). One size fits all just doesnt work in these situations.