Palliative care addresses medical, emotional issues
Results include better pain control, shorter stays
A palliative care program has resulted in better symptom control and pain management, decreases in length of stay for patients, and potential cost savings for Methodist Medical Center in Oak Ridge, TN.
The palliative care program, implemented in October 2005, is an outgrowth of the Comfort CareTrax program, implemented by the medical center in 1998 to improve the quality of care for patients at the end of life, according to Melissa Jones, BSN, RN, CCM, case manager and palliative care nurse coordinator at Methodist Medical Center.
Jones was on the team that developed the Comfort CareTrax program, which won national recognition.
The program's goals include pain management and control of other symptoms, addressing advance directives and entering them on the chart, addressing the patient's level of hope, and helping the patient and family define immediate and long-term goals of care.
"Although decreased length of stay and costs were not the primary objective, it was felt this would occur if we followed the patient's wishes and eliminated unnecessary tests or unnecessary transfers to the acute care unit," Jones says.
A financial analysis, based on a formula developed by Mt. Carmel Medical Center in Columbus, OH, showed a projected savings of $390,679 a year, Jones says.
The typical definition of a palliative care patient is someone with a chronic illness that will eventually lead to death, Jones says.
"It could be five or six years down the road. We start addressing all the issues and talking about goals of care, even looking at social, emotional, and spiritual issues," she says.
In just over a year, 199 patients were referred to the program, including patients with cancer, end-stage renal disease, end-stage liver disease, gastrointestinal disease, stroke, AIDS, respiratory disease, and cardiac disease.
Patients who are in the palliative care program are on units throughout the hospital. Jones coordinates their palliative care, working with the case manager and social worker on the unit, the nursing staff, physicians, dietician, physical therapist, respiratory therapist, and home care coordinator.
At Methodist Medical Center, case managers are assigned by physician group. In addition to her duties as palliative care nurse coordinator, Jones is the case manager assigned to the hospital's oncologists.
"I'm already going over these kinds of issues with patients on the oncology unit. It comes naturally for me to do it with anybody I see," she says.
Beginning Jan. 1, Jones is devoting three full days a week to the palliative care program while someone else takes over her other case management duties.
"The hospital steering committee really likes the program. They've given us this extra time to help us provide services to the patients who need it," she says.
The program requires a physician's order before a patient can be referred for palliative care.
When Jones receives the order, she conducts an assessment to determine the patient's and family members' needs and helps them start a discussion about end-of-life issues.
"A lot of the frustration with hospice and comfort care occurs because people have to deal with issues they should have been thinking about months before. We help them start thinking about what may happen in the future," she says.
Jones talks with her patients and family members about advance directives and helps them complete them or at least get started talking about them.
"The goal of palliative care is to start people having serious conversations when it's not an end-of-life crisis. They may know that they won't be cured, but it's much easier if we can give psycho-social and spiritual support now, and not when there's a crisis situation," she says.
When Jones meets her palliative care patients for the first time, she asks them about their understanding of what their doctor has told them about their illness.
"We start from there. My job is not to change their minds about advance directives. My job is to make sure we understand as a hospital what their goals are and to help them achieve their goals," she says.
She assesses the patient's functional status to determine if they can perform activities of daily living without help and may bring in physical therapy to assess their needs.
Sources of support
Jones often asks the social workers to help deal with family and social issues or calls in a chaplain for spiritual support.
She helps them identify community resources and teaches the patient and family members symptom management at home.
"I educate them on everything from pain management to constipation or shortness of breath and tailor the education to the patient's individual needs," she says.
She arranges community support, whether it's referring them to support groups, arranging for home health, or setting up medical equipment.
"I'm there to give the patients information and support. I sit down and spend as much time as it takes to listen to all of their concerns. I may sit and cry with the family. I know I can't make everything right, but I can be there to listen and lend support. Sometimes 'touch' and 'presence' are more important than any words I could say," she says.
She works closely with the case managers and social workers on the unit when a patient needs to go to a skilled nursing facility or needs an insurance precertification. If the palliative care team recommends changes in the discharge planning for the patient, she notifies the case manager.
If there are symptom management or medication issues, she calls in Ronald Lands, MD, the medical advisor for the palliative care team.
"A lot of what I do is facilitating communication. I get the treatment team and the family together so everybody will be on the same page," she says.
Getting the family members with all of the patient's physicians at one time helps everybody understand the patient's true prognosis and condition, she says.
For instance, the family may cling to the cardiologist's declaration that the patient's heart is doing well but the nephrologist may be telling them that the kidneys are failing. The family meeting can address those issues, she says.
The palliative care treatment team has weekly meetings to discuss the plan of care for all of the patients in palliative care. The team includes Jones, Lands, a dietician, a social worker, the director of nursing, managers on the oncology unit, and clinical nurse specialists from the acute care unit, the patient's case manager, and a pharmacist when needed.
"With the palliative care patients, we see and evaluate everything that is going on with the patient and family and set up multidisciplinary conferences for the families so they'll know what they're facing and have all the information they need to make decisions," she says.
The team shares information and articles on palliative care and discusses them and supports each other as they care for terminally ill patients.
"Our group meetings are like a therapy session. We are a small group, and we let our hair down. We discuss patients and their issues, but sometimes we have issues of our own and we help each other," she says.
[For more information, contact Melissa Jones, BSN, RN, CCM, case manager and palliative care nurse coordinator at Methodist Medical Center, e-mail [email protected]]
A palliative care program has resulted in better symptom control and pain management, decreases in length of stay for patients, and potential cost savings for Methodist Medical Center in Oak Ridge, TN.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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