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Discussion: End of Life Care.

End of Life Care

Eduardo Roqueso

Florida National University

Advanced Family Practicum III

Jacqueline Alonso DNP, Family ARNP

            The ability to provide primary palliative care is a skill set that nurse practitioners should acquire, develop, and refine. Primary palliative care skills include thorough and effective symptom assessment and management, initiating and guiding conversations around advance care planning, and completing medical directives that guide care with life-limiting/life-threatening illness (Wheeler, 2016). Although sometimes confused with hospice, it’s important to remember hospice is a specific type of palliative care designed to address the needs of those who have 6 months or less to live. In other words, hospice care is always palliative, but not all palliative care is hospice care. (IPC, 2018).

            As frontline clinicians, APRNs, along with their RN colleagues, spend the most time with patients at their bedside. All APRNs must have fundamental palliative care skills. This includes understanding illness trajectories from diagnosis to death, appropriate assessment and management of pain, particularly in the current opioid misuse epidemic b (Dahlin & Coyne, 2019).

            The most recognized area of leadership for APRNs is Clinical Care. To be successful, APRNs must understand the diagnosis and the natural course of illnesses and diseases along with the critical decision-making points to manage and treat these conditions from diagnosis to end-of-life care, based on best available evidence. APRNs are in a key position to deliver collaborative interdisciplinary palliative care for patients with serious illness and move palliative care upstream to caring for populations across the lifespan and across the health care continuum (Dahlin & Coyne, 2019). 

            In palliative care, when presenting with a symptom complaint, disease progression must always be considered. Disease progression needs to be identified to help with the ongoing goals-of-care discussions. Often-cited symptoms include pain, breathlessness, fatigue, anorexia, nausea/vomiting, constipation, depression, dry mouth, and sleep disturbance (Wheeler, 2016)

            In a perfect palliative care world, advance directives for care at end of life would be documented, medical powers of attorney would be named, and these documents would be shared with all health care providers. The reality is that this does not happen, and many hospitalizations are for a crisis when decisions need to be made and there has not been an open and honest discussion of the illness trajectory. NPs enter into these discussions without an agenda for what are the “correct” decisions. The desired outcome is to have the patient understand the issues and make informed choices based on their goals and their definition of quality of life. NPs need to be prepared to discuss disease trajectory, realistic interventions, and prognosis. Palliative care advocates that advance care planning be documented and revisited with subsequent changes in health status (Wheeler, 2016).

References:

Dahlin, C., & Coyne, P. (2019). The palliative APRN leader. Annals of Palliative Medicine, 8(1), S30-S38. doi:10.21037/apm.2018.06.03

IPC. (2018). Palliative Care: The Next Frontier for APRNs? Retrieved from CSU Institute of Palliative Care: https://csupalliativecare.org/palliative-care-aprns/

Wheeler, M. (2016). Primary Palliative Care for Every Nurse Practitioner. The Journal for Nurse Practitioners, 12(10), 647-653. Retrieved from https://www.npjournal.org/article/S1555-4155(16)30503-7/pdf

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