Promotion of Excellent Quality Palliative Care for End-of-Life Patients

Palliative Care for End-of-Life Patients

Problem Description: Amenable to Nursing Intervention
Problem Description

The healthcare given to the critically ill and those at the end-of-life is experiencing significant changes. End-of-life (EOL) has a high profile in the international healthcare sector and among critical care units. However, EOL care in the U.S. remains a debate, as it presents multiple challenges to healthcare practitioners, especially nurses (Coombs, Long-Sutehall & Shannon 2010). This proposal finds that EOL care nurses face challenges from families that are demanding for aggressive care for EOL patients. The other challenge for EOL nurses is the American belief that treatment is torture, clinically, and ethically inappropriate for EOL patients (Coombs, Long-Sutehall & Shannon 2010). The third challenge for EOL care is the lack of resource allocation by hospital, nursing home, or government administration. Reading the studies, it is evident that the EOL care system is facing conundrum due to the legal balance between the definition of the terms decision-making of EOL patients and their families (Coombs, Long-Sutehall & Shannon 2010). Therefore, the futility debate in America about EOL care is about the shift of the weight to clinicians, to hospitals, state or to the family and community.

Target Population and Setting for EBP

This research prepares a plan for the improvement of a comprehensive and compassionate palliative care for EOL patients. The plan targets patients in America’s acute care units in hospitals, nursing homes, homecare setups, hospice, and sub-acute centers. The target population is all patients in these locations and therefore covers the following groups of EOL patients:

These are adults and children with congenital conditions that are on life-sustaining treatments, long-term care with the support of others in activities of daily life.
This also includes people of all ages with acute, life-threatening, and serious illnesses like leukemia, acute stroke, which cure of these illnesses is irreversible. Where cure is reversible, conditions and treatment pose difficulties and burden on the quality of life.

In addition, this includes people with progressive chronic illnesses and conditions like malignancies, peripheral vascular disease, and stroke with advance functional impairment, chronic liver and renal failure. This also includes persons with advance lung and heart disease, dementia, and neurodegenerative disorders.

The plan also targets people with life-limiting and chronic injuries from trauma and accidents.
Lastly, patients with terminal and serious illness like end-stage dementia, severe disabling strokes, and terminal cancer. These are the patients unlikely to recover.
Significance of the Problem to the Population

The research focuses on this population since the National Statistics indicate that there is a rise in the number of deaths and those in EOL putting pressure on existing EOL services (Tilly & Wiener, 2003). This is because of challenges in the society of how critical care is achievable in EOL consensus. The expectation is that the palliative caregiver will address quality of life for patients with life threatening illness and that of their families. This research identifies that these challenges arise, from the reluctance of the American society, to discuss the dying and death. The principle of palliative care is that it offers EOL patients preventative, treatment, and assessment of emotional and physical problems as a curative therapy. However, the challenge for this care is the social definition of futility of treatment and quality of life in EOL (Coombs, Long-Sutehall & Shannon 2010). Palliative care is to affirm life, present death to the patient and family as a normal process. Palliative care for EOL patients seeks to neither hasten nor prolong life, but it is a curative therapy.

The challenge in EOL care is the social influence management and a lack of continuity in the provision of care are the main barriers to quality EOL care (Ferrell, 2000). This is because, in EOL care, the society has concerns and influences the management of symptoms and pain. EOL patients still deserve excellent care, emotional and physical support (Beaver et al., 2000). Despite the fact that they do not have a hope of recovery, palliative care must intervene in distress, offer comprehensive and compassionate therapy. This also must include the preparation of the family for death and facilitation of ethical principles of justice in EOL care.

The second reason for targeting this population is the increasing demand by the society for the care of those at EOL. The problem is a challenge for this population since the society expects that healthcare providers will make judgments for EOL patients that cannot make decisions for themselves. The society does not consider the need for explicit and comprehensive care for EOL patients (Coombs, Long-Sutehall & Shannon 2010). Moreover, the perception is that there is no need to improve the quality of life for EOL patients. For the target population, quality of life treatment creates a debate of the futility of this care in medical and nursing staff and the family (Coombs, Long-Sutehall & Shannon 2010).Therefore, due to these perceptions, EOL patients move to nursing homes, homecare setups, hospice, and sub-acute centers to await death.

This will entail the definition of palliative care, its goals, and guiding principles. The plan describes the strategy for providing a comprehensive and compassionate care for EOL patients while improving communication with family. The goal of the plan is to create a detailed approach that educates and supports nursing care on essential issues in EOL care. The goal is that, in the end, nursing practices, research, and education reflect ethical palliative care for this demographic by focusing on both the physical and psychological health of patients.

Clinical Guidelines and Best Practices for Palliative Care
Clinical Guideline and Best Practice

Palliative care is that which affirms life and embraces death as a normal process. Palliative care offers relief from physical pain and considers the spiritual and psychological dynamics of patient care (NCPC, 2000). The practice gives a support system to assist patients to live actively, as much as possible until their death. Moreover, palliative care offers the families of EOL patients a support system to cope with the illness of their loved ones and their environment (NCPC, 2000). To this end, palliative care is to be an active and holistic care given to EOL patients. It is essential that the nurse provide social, emotional, psychological, and spiritual support along with the basic nursing care of pain management (Beaver et al., 2000).

The fundamental elements of palliative care are:

Symptom and pain control, spiritual and psychological distress management, and addressing practical needs of the patient and family with a continuum of care.
Patients and family receive ongoing information in an appropriate, culturally sensitive, and understanding manner to allow for the achievement of a comprehensive and realistic treatment. In the process, this care elicits the processes, values, goals, preferences, and beliefs. The palliative must continually reassess the benefits and burdens of treatment, with decision-making process on care plan aligned to patient’s conditions.

Palliative care also involves a genuine coordination of the healthcare across all settings through high quality and regular communication with providers during times of transition, changing needs, and by effective case and care management.

This also involves the appropriate preparation of the patient and family for death and the dying process. Exploration of various hospice options, enhancement of opportunities for personal growth and bereavement support for family.

These standards are to match the EOL care requirements, which entail:

The education of nurses entails palliative care, EOL care, and acute care of patients with terminal illnesses. Education and training on how to assist patients and families deal with anxiety and depression, panic and fear, fatigue, weight loss, insomnia, pain, and social needs. Education also entails the provision with skills and knowledge to communicate, relate in decision-making with patients and families.
The EOL nurse caters for the patients’ communication and information, accurate diagnosis, symptom control, coordination care, social and spiritual needs physical and emotional support.

Need end of life planning by considering a patient’s wishes for future treatment, and preferred place of death.

Operational Definition of Palliative Care

The “Clinical Practice Guidelines for Quality Palliative Care” define palliative care as the effective pain and other symptoms management, with the incorporation of spiritual and psychological care. This also considers the needs, preferences, beliefs, values, and culture of the patient and family.

Benefits of Palliative Care

The palliative care approach is advantageous over basic EOL care since it is rich in the art of caring. The palliative care approach promises to offer more comprehensive and compassionate care to EOL patients. Moreover, the palliative care uses the principles of psychosocial, psychological, and spiritual support of the patients and their families (Beaver et al., 2000).

Evidence Based Research

Han and Miller (2008) carry out an empirical study of nursing homes in the U.S. The study finds that nursing homes lack the ability to meet the needs of pain management of residents and EOL patients and families. The study made use of data from National Nursing Home Survey in 2004, for 1174 nursing homes and country level data from Area Resource File and nursing home online surveys, reporting data and certification. The study’s variables include study outcome, which entail the special programs in the nursing homes. Of interest in this variable is hospice and palliative or end-of-life care. The study also includes variables about the nursing homes like healthcare management, formal hospice contract, other types of contracts, and other special programs. The tools of data analysis entail the X² tests and regression model. Of those surveyed, only 27% had hospice, palliative or EOL care. The survey shows that majority of the nursing home administrators’ contract outside providers, and specialty programs as their hospice, palliative, or EOL care. The largest positive effect to EOL patients was in the nursing home programs, which deal behavioral problems like confidence and pain management.

A study by Luker and Willard (2006) explores the care and treatment preferences for patients at the EOL. This empirical research discusses the challenges of appropriate EOL care found in UK’s acute hospitals. It highlights the settings contribute to the exclusion in decision-making of patients’ and families’ treatment and care requirements. The study shows that these patients opt for comfort rather than the extension of life. EOL patients also prefer to participate in decision-making activities and wish to die at home (Luker & Willard, 2006). The research problem identifies that despite these wishes majority of EOL patients die in acute hospitals, where EOL interventions are inappropriately aggressive and invasive. To solve this problem, the researchers made use of semi structured interviews and observation of nurse specialists. The empirical study made use of 29 UK cancer nurse specialists, drawn randomly from five hospitals. The research made use of the grounded theory as its study method to uncover the problems that nurse specialists face and how they manage the problems. The research selected hospital-based registered nurses with expertise in palliative care to ensure the inclusion of valuable information. The composition of nurses entails three nurse practitioners, two research nurses, eleven tumor specialists, nine palliative care, and four critical care nurses. A comparative method analyzed the results from the observations and the interviews. The results of the research show that EOL interventions are under the influence of preoccupation with routine practice, treatment, negative perceptions of palliative care (Luker & Willard, 2006). These factors are behind the prevention of clinical decision-making in EOL by patients and families. The research shows the need for professional and morality in involving patients and families in decision-making. This is to entail the provision of information and the encouragement of the involvement of patients at every stage (Luker & Willard, 2006). In addition, there is need for exploration of patient’s preferences in advance, use of advance EOL care plans. This also entails the use of the palliative care philosophy of “good death.” The findings play a key role in changing the EOL care given to end-of-life patients within the acute hospital set up. This is because Luker and Willard (2006) make use of principles of palliative care with those of the acute care nurse to improve the care given to EOL patients.

Plan for Implementation
Implementation Strategy for palliative care services for EOL patients 2013-2018
To achieve this plan, the plan requires a five-year period for the improvement of palliative care for EOL patients to reach the comprehensive and compassionate levels required. This begins with the identification of frameworks that define priority services for palliative care development in the next five years, as:
1. The improvement of palliative care service delivery and planning,
2. Implementation of the standards of the provision of quality palliative care for all EOL patients,
3. Improvement of palliative care workforce training and capacity,
4. Improvement of palliative care data,
5. Strengthening of evidence based practice.
This will begin with the setting out of actions in achieving the policy vision. Actions entail patient and family centered activities, pain and symptom assessment and management practices, monitoring and control and assessment of best practices against outcomes.

Improvement of palliative care services target audience are all clinical staff, allied health, clinical, nursing, palliative care, pastoral care, and advanced care planning.

A period of six months is necessary to offer adequate training and education on palliative and EOL care.
The implementation of strategic framework is through the American Palliative care service department and the EOL service department.
The palliative care strategic framework will be reviewed in January 2014 to evaluate progress of action plans.

Actions plans involve:
1. Patient population: palliative care must care for all patients from all ages with debilitating chronic illnesses, injuries, and conditions.
2. Palliative care must be family- and patient-centered care. This is where the palliative care is given according to the uniqueness of the family and patient preferences, and will entail their involvement in decision-making.
3. Timing: palliative must begins now of diagnosis of the debilitating illness, condition, or injury, should continue until the death, and right into the bereavement period of the family.
4. Comprehensive care: entailing multidimensional assessment to identify suffering from physical, psychological, spiritual, and social distress.
Outcomes and what the assessment of strategy will report on:
1. Patient and family access to palliative care expertise,
2. Palliative care policy frameworks in place in the various institutions,
3. Local palliative care service arrangements in place between various institutions,
4. Study of palliative care services training and education,
5. Evaluation and assessment completed,
6. Progress of the implementation of the palliative care service pan,
7. Recommendations needed for future palliative care development and expansion.

Expected outcomes, by the first assessment in 2014 and the summative assessment in 2018:
1. Increase in access to specialist palliative care by patients and family in need,
2. Discussion, documentation, and adherence to advance care plans,
3. Increment of pain management assessment among palliative care practitioners,
4. The realization of fewer inappropriate referrals to acute hospitals.
Personnel and Resource Allocation

Implementation will take place with the assistance of qualified and validated EOL and Palliative care nurses. This implementation plan will require training and educational seminars with professional palliative care providers. For the plan to be effectively implemented palliative, EOL, and critical registered nurses, will involve district and primary care providers. This will also take into consideration nurses working with EOL patients in hospices, nursing homes, elderly homes, and acute centers. Professionals also include those from core healthcare sectors like medicine, social work, nursing, including volunteer coordinators, chaplains, pharmacists, and psychologists. These also involve bereavement coordinators, language and speech pathologists, child-life therapists, music, play, art, case managers, and physical therapists.

Feasibility of the Strategy

The initiative is feasible since it draws protocols from the UK’s Department of Health palliative and EOL standards. Collaboration with hospital hospice, acute centers, nursing homes administrators, and the community will ensure the sustainability of the plan.

Cost Effectiveness, Safe, and Quality of Practice

Cost effectiveness is achievable with available training materials on EOL and palliative care from the department of health. The use of administrative staff and validated nurses from the institutions to assist in training and implementation will ensure the promotion of quality practice. Quality of EOL and palliative care is through the matching of protocols, EOL, and palliative care goals to the gold standard framework. Quality is achievable through effective communication between palliative care nurses, patients and their families a long with support care givers.

References

Adler, S.R., Anderson, W.G., Cimino, J.W., Dzul-Church, V., and Wong, P. (2010). “I’M Sitting Here by myself …”: Experiences of Patients with Serious Illness at an Urban Public Hospital. Journal of Palliative Medicine, 13(6), pp. 695-703.

Beaver, K. et al (2000) Primary care services received during terminal illness. International Journal of Palliative Nursing, 6, pp. 220–227.

Buckingham, R.J., Buxton, K.L., Pursey, N.A., Roberts, C.M. and Stone, R.A. (2010). Current and Planned Palliative Care Service Provision for Chronic Obstructive Pulmonary Disease Patients in 239 UK Hospital Units: Comparison with the Gold Standards Framework. Palliative Medicine, Sage Publication, 24(5), pp. 480-485.

Coombs, M. and Long-Sutehall, T. and Shannon, S. (2010). International Dialogue on end of Life: Challenges in the UK and USA. Reflective Analysis; Nursing in Critical Care, British Association of Critical Care Nurses, 15(5), pp. 234-241.

Gandy, R. and Roe, B. (2012). Using Care Profiles as a Catalyst for improving end of Life Commissioning, Involvement and Service Delivery. BMJ Supportive & Palliative Care doi:10.1136/bmjspcare-2012-000214.

Han, B. and Miller, S.C. End-of-Life Care in U.S. Nursing Homes: Nursing Homes with Special Programs and Trained Staff for Hospice or Palliative/End-of-Life Care. Journal of Palliative Medicine, 11(6), pp. 866-878.

Luker, K. and Willard, C. (2006). Challenges to end of Life Care in the Acute Hospital Setting. Palliative Medicine, 20, pp. 611-615.

National Council for Palliative Care (formerly the National Council for Hospice and Specialist Palliative Care Services) (2002) Care. Briefing Bulletin 11. London: NCfPC.

Tilly, J. and Wiener, J.M. (2003). End-of-Life Care in the United States: Policy Issues and Model Programs of Integrated Care. International Journal of Integrated Care, 3, pp. 24-31.

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