What Nurses Need to Know About Palliative Care

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Who You’ll Hear

Kati Kleber, MSN RN– Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

Kathleen Puntillo, PhD RN FAAN is professor emeritus of nursing at the University of California, San Francisco (UCSF). At UCSF, she was director of the Critical Care/Trauma Graduate Program for many years and founded UCSF’s Acute Care Nurse Practitioner Program, and has published extensive research throughout her career and received many awards. 

What You’ll Learn

• Introduction
• Difference between palliative care and hospice
• Palliative Care examples
• Benefits
• Advice
• Communication
• Talking to the Family

What Nurses Need to Know About Palliative Care

In this episode, we interview Kathleen Puntillo, Ph.D. RN FAAN who has written about and researched palliative care extensively, about what the nurse needs to know about palliative care and considerations for their patients.

Introduction to Kathleen Puntillo, Ph.D. RN FAAN

• Winner of the 2017 AACN Pioneering Spirit Award

• Professor and Research Scientist in the School of Nursing at the University of California San Francisco

• Since 1999 she has been involved in research related to the integration of palliative care with critical care

Difference between palliative care and hospice

Defining the difference between the two and when a patient might qualify for palliative care but not for hospice.

• Palliative care – a philosophy of providing care to people with serious illnesses, and providing this care to their family as well.
  3 key domains of palliative care:
  • Symptom Management
  • Communication
  • Family Engagement
• We practice palliative care by looking at these domains and introducing into our practice what the patient and their family need.

• Hospice patients always receive palliative care, frequently in their home.

Palliative Care Examples

Simple examples of a patient for whom palliative care is perfect but they are not in hospice:

• Congestive heart failure
• Lung diseases
• They have a disease that is going to be constant over a period of time
• They might not be at the end of their lives
• They might have a serious illness, but it isn’t the illness that will kill them tomorrow.
• They have needs for symptom management
  • Thirst
  • Fatigue
  • Pain
• They aren’t ready for hospice but they have needs for palliative care
• Hospice care is for patients with 6 months to live or less.
• You don’t have to be dying to receive palliative care.
• Every patient in the ICU needs palliative care.

Benefits of Bringing Palliative Care on Earlier

There are many benefits to bringing on palliative care early, especially in the ICU.

• When patients are in the ICU, their care is complex, and there are multiple physicians seeing them.
• Palliative care helps put the pieces together for the family.
  • Please note that physicians don’t always agree with this.
• There is a misunderstanding that palliative care is the same as the end of life care.

Advice for New Nurses About Verbalizing Need

Advice for new nurses who identify a need for palliative care but are having challenges expressing that effectively:

• It happens very often.
• Physicians misunderstand what palliative care is.
• There are 2 kinds of palliative care:
  • Primary palliative care – The type of care that can be provided by the patient’s primary physicians.
    • Can we address symptoms like pain and shortness of breath?
    • Can we communicate with the family?
    • Yes, we can provide this care at the bedside.
  • Specialty or consultative palliative care –  When you say “can we call palliative?” you mean “can we bring in the palliative care service,” that is specialty palliative care.
    • Particular ICU patients might not need specialty palliative care service if their needs can be met by their own clinicians in the ICU
    • Sometimes that means bumping up our knowledge about assessing symptoms and looking at the collective picture
• When do you call in palliative care?
  • If the patient’s situation is very complex, their symptoms aren’t being managed the best, or if it is a family that is completely not handling the situation, it may be better to bring the specialist in.
• Don’t think that starting palliative care means you are stopping curative care.
  • They can be addressed side by side.
  • Don’t think you have to make a choice.
  • Curative care might not be enough for some patients. If they approach the end of their life, the balance of care changes from more curative and palliative to more palliative care.

Nurse and Surgeon Communication

An example of when a nurse can offer education and use good communication.

• What does the nurse mean by “can we call palliative”?
  • Know the difference between primary and consulting palliative care.
• Example: a patient is having a lot of trouble with symptoms. The nurse could say to the surgeon, “I’m thinking that maybe this is a patient that is good for palliative care,” to bring the palliative care team in. The surgeon says, “my patient isn’t dying.”
  • Then the nurse would say, “Alright. But here is the situation. The pain is ___, and I know you don’t have all the time in the world to be addressing all these issues. I know the palliative care service does a great job with symptoms. Do you think we could call them in, to help manage the patient’s symptoms?”
• Show respect to the surgeon with the NURSE process –
  • Naming – “I know that you are very busy.”
  • Understand – “You are in surgery now and can’t come down.”
  • Respect – “I really respect your expertise”
  • Support – “Can we get some support, not just for you but for the patient, through calling the palliative care service?”
  • Explore – “Can you tell me a little bit more about your thoughts now?”

How to let the family know about palliative care without making them think about hospice and dying.

These are tips for the brand new nurse that has to speak to the family about palliative care without making them worry about hospice and dying.

• You might start out by just asking some questions:
  • Find out where they are what their understanding is of the situation.
• Try and gauge where they are at and what their understanding of the patient’s condition is.
• Listen to them describe it and notice the gaps in understanding or if they describe it incorrectly.
• Another communication skill
  • Ask – what is your understanding of what is happening?
  • Tell – these are some of the things I am worried about and things the physician has said to you
  • Ask – does this make sense to you? How are you feeling now?
• Communication is a procedure. You can learn and have a toolbox of communication skills you can use.
• You are there to support the family.
• Family meetings should always include a nurse. You don’t need an invitation. This is your patient. When you are there, you know what is being said, you can provide support to the family.
• Explaining palliative care to the family could be tricky.
  • You may not need to use the word “palliative” in the beginning.
  • You might say, “it seems like we could use some help here. We have some people here that might be helpful to you.”
  • When you feel the time is right you can explain what the palliative care service does. They are really good at symptom management, etc.
• The better your knowledge base is, the more you can advocate for your patients.

More Resources on Palliative Care:

• AACN.org
  • American Association of Critical Care Nurses – valuable resources
• Something You’re Dying to Talk About – Fresh RN Blog
• The Unexpected Patient: Tips for Nurses Caring for the Seriously Ill from the Family Perspective