Palliative Care - Interview with a Nursing Leader

Patients are surviving longer with more chronic illnesses. They survive cardiac arrests, and multi-system traumas. Our patients today survive what once was unsurviveable. However we are often left with questions….what should we do now?

Palliative Care - Interview with a Nursing Leader

AN recently interviewed Dr Terri Maxwell who is the chief clinical officer of Turn-Key Health where she is responsible for clinical care delivery, competence and quality. In addition, she serves as vice president, Clinical Education, Enclara Pharmacia, an affiliate of Turn-Key Health. A recipient of a Project on Death in America award from the Soros Foundation, Dr. Maxwell previously served as vice president of Strategic Initiatives, Weatherbee Resources Inc. and the Hospice Education Network. She also held a number of executive positions at Hospice Pharmacia, and established the Center for Palliative Care in the Department of Family Medicine at Thomas Jefferson University. A widely published author and frequent presenter at state and national meetings, Dr. Maxwell has served on a number of committees and editorial review boards, including the National Hospice and Palliative Care Organization (NHPCO) Relatedness subcommittee, NHPCO QAPI NCHPP steering committee, NHPCO Research committee and the Journal of Pain and Palliative Care Pharmacotherapy's editorial board. Dr. Maxwell earned a master's in Nursing and a Ph.D. in Nursing Science from the University of Pennsylvania, and a bachelor's in Nursing from the University of Rhode Island. In 2010, the College of Nursing at the University of Rhode Island made her a dean's list honoree at its Distinguished Achievement Awards.

We discussed palliative care and the initiatives seen in this area recently. She offered varied insights into this nursing specialty and how it encompasses so much of what we, as nurses do every shift.

Palliative care continues to advance end of life care in the US. What do you think is the biggest advance in this field in the last 5-10 years?

There have been so many advances in palliative care in the past 5 to 10 years. Some of the ones that come to mind include:

The role of palliative care in the health care system has grown in importance as people are living longer with chronic diseases and face a multitude of decisions about the use of technology, medications and therapies at the end of life.

In the last decade, palliative care has matured as a recognized, specialized, medical and nursing field.

In addition, there has been an explosion of articles and books about death and dying for lay people that has helped to create discussion about facing one's mortality at the end of life and the importance of quality over quantity of life.

Lastly, there has been an enormous expansion of programs throughout hospitals and more recently, into the community, to care for people with serious illness in their homes or in nursing homes.

Hospital-based palliative care services are expanding as advances in chronic disease management lead to longer lives. How does palliative care function in a hospital system?

Hospital-based palliative care programs vary in team composition and delivery models from hospital to hospital. Most are comprised of specially trained physicians, nurses, social workers, pharmacists and chaplains who provide consultative services.

These services generally focus on the provision of expert symptom management, help navigating the healthcare system, goals of care discussions and family meetings. These provide opportunities to offer support for decision-making, emotional and spiritual support as well as providing assistance to staff in caring for their seriously ill patients.

What traits are important for a palliative care nurse to develop?

Important traits of palliative care nurses include empathy, which is the ability to understand and share the feelings of others, compassion, the concern for others, and respect for human dignity. Communication and listening skills are critical, as is resilience in order to meet daily challenges, recover from difficulties and help to prevent burnout.

According to the National Hospice and Palliative Care Organization, the focus of palliative care is utilized across the continuum of care from pediatrics to geriatrics. How does palliative care differ among the patient populations?

The essential concepts and primary domains of care as outlined in the National Consensus Project for Quality Palliative Care (2009) are similar across patient populations, as are the needs of patients and their loved ones. However, there are differences in care goals and ways in which decisions are made, especially among those who are younger.

Palliative care teams need to also recognize differences in disease states and disease trajectories across the age spectrum, have specialized knowledge related to medication management for the very young and very old and alter their communication strategies as appropriate.

How do you see palliative care advancing in the years to come?

I expect to see greater diffusion of palliative care into the community, hopefully supported by new payment methodologies that do not limit access with restrictive eligibility requirements. As we move beyond a fee for service (FFS) model to a value-based payment methodology, health care payers and providers will increasingly recognize the value of palliative care.

What is needed is a more comprehensive and coordinated palliative benefit for those with advanced illness who otherwise fall through cracks in care based upon CMS regulations for Home Health Care and Hospice. As palliative care grows, we will need to address workforce deficits and training needs. I also hope to see greater integration of palliative care concepts into medical and nursing school curriculums.

Thank you Dr. Maxwell for your comments.

So...how does your hospital system, facility or practice utilize palliative care?

Here is a roll call of AN Palliative Care nurses

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Specializes in Family Nurse Practitioner.

We work in a team at my facility. We have a MD, 2 NPs, & a PCSW. We provide symptom management for chronic & life-limiting illnesses, have family meetings to determine goals of care, assist with advanced care planning, offer support, and assist with connecting families with hospice when appropriate.

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Specializes in Surgical, quality,management.

Here in my Melbourne experience.....

The 2 medical specialities on my ward have polar opposite views.....my gastroenterology/ hepatology unit battle until the patient is practically dead and then withdraw rapidly causing distress to the families.

My acute geriatric orthopaedic unit however talk about death, EOL planning, advanced care planning etc with all patients.

My leadership group and SW get very frustrated with the gastro docs when both the nurses and patient recognizes dying but the doctors refuse to acknowledge it.

Our hospital has an inpatient unit for EOLC and discharge planning, as well as an outreach service to the wards that my ortho geris use frequently.

There is also a RAPID community program for both palliative patients in the community and nursing homes.

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Specializes in Nephrology, Cardiology, ER, ICU.

Great insights. I work in a large hospital with heart failure pts. I had previously worked with dialysis patients. Both populations have high mortality. We have a very large palliative care practice both inpt and outpt. However, it always seems like they are super busy. They provide a much-needed service for our pts and families

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