Background: The palliative care needs of hospitalized patients often go unmet, resulting in unrelieved symptoms and a lack of understanding about advance care planning.
Objectives: This article analyzes the 10-item Palliative Assessment Screening Tool (PAST) to determine if the PAST aids in the identification of hospitalized patients with palliative care needs and facilitates completion of advance directives.
Methods: A systematic review of studies published from 2012–2016, as well as a retrospective chart review, were used to analyze the PAST. For this 12-week pilot study, all adult patients either admitted or transferred to a 24-bed medical-surgical oncology/orthopedic unit were assessed by the bedside nurse for their potential palliative needs.
Findings: Using the PAST seems to improve the identification of patients with palliative needs, leading to better management of symptoms. The PAST is also likely useful in facilitating the completion of advance directives, but this requires further study.
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Palliative care is aimed at improving the quality of life of patients faced with life-threatening illness and their families. This is done “through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (World Health Organization, n.d., para. 1). Such improvements in quality of life are made possible by early integration of the patient’s values and preferences into the plan of care. Evidence suggests that palliative care interventions improve symptom management, reduce length of hospital stay, and increase patient satisfaction (Campbell, Weissman, & Nelson, 2012). However, barriers often stand in the way of achieving these goals, such as lack of palliative care education and insufficient training and tools to guide nurses in identifying patients’ potential palliative care needs. As a result, palliative care is often not implemented until the late stages of illness (Perrin & Kazanowski, 2015). Nurses can overcome educational barriers by ensuring that healthcare providers, patients, and families understand the benefits of palliative care and by making early referrals to palliative care services (Perrin & Kazanowski, 2015). Early integration of palliative care into the management of patients with serious disease has the potential to improve quality-of-life outcomes for patients (Aldridge et al., 2016).
Insufficient training and tools are barriers that are more difficult to overcome. Early identification of patients with a high likelihood of unmet palliative care needs is essential to providing timely and effective palliative interventions. The need is great for a standardized screening tool to identify palliative care needs (Lapp & Iverson, 2015). A collaborative approach in which RNs use clinical screening criteria within electronic health records (EHRs) to identify patients in need of palliative care services can help to facilitate referrals to qualified providers (Cox & Curtis, 2016). The current article describes the results of a 12-week pilot study of the Palliative Assessment Screening Tool (PAST), which was created by and used on a medical-surgical oncology/orthopedic unit at St. Joseph Hospital, a community hospital in Nashua, New Hampshire (see Figure 1).
The current study was a retrospective chart review that took place from January 19 to April 12, 2016. The study was approved by the institutional review board of Saint Joseph Hospital. The purpose of this study was to analyze how the PAST could guide staff nurses in the early identification of the palliative care needs of their patients and whether the tool helped these nurses obtain referrals to a medical palliative care provider to improve patient outcomes, particularly symptoms of pain, nausea, and shortness of breath. Palliative interventions (e.g., medications, positioning, spiritual care, emotional support) were studied for their effectiveness. The study also examined how palliative care affected patients’ plans of care in other areas, such as the completion of advance directives.
Inclusion criteria were being aged 18 years or older and having been admitted or transferred to the medical-surgical oncology/orthopedic unit of St. Joseph Hospital. Exclusion criteria were having a substance abuse disorder and having no palliative care needs (determined after interprofessional review). Six of the 50 patients identified as those who would likely benefit from the services of a palliative care provider were identified twice because of readmission; only one admission was counted. Overall, 44 participants were identified for participation in this study (see Figure 2).
Existing literature concerning palliative care, palliative care screening tools, and palliative education for inpatient nurses was reviewed using EBSCO. Keywords used were as follows: palliative care, screening, identification, symptom management, advance directives, medical-surgical units, intensive care units, and education.
The overall findings of the literature review suggest that palliative care improves outcomes for patients, particularly in the areas of symptom management, advance care planning, reduced hospital stays, and patient satisfaction. Also noted in the literature were the many barriers that stand in the way of providing palliative care services to hospitalized patients; these include lack of standardized assessment tools, misperceptions, and insufficient education about palliative care among healthcare providers. The literature also included articles describing how the use of technology and the incorporation of palliative care screening may help clinical staff (e.g., bedside nurses) identify patients who require palliative care consultations.
This review of the literature was crucial in understanding the benefits of and barriers to palliative care consultation in hospital settings, and the information found during the literature review served as evidence when creating the PAST, developing a method for using it, and crafting an educational rollout for bedside nurses on the study unit.
Following review of the literature, clinical leaders on the unit developed a 10-question survey (PAST), which was used by staff nurses during the admission or transfer assessment of patients. Information to complete the PAST for each patient came from direct patient interview, as well as from data found in the patient’s chart and history, taken from the EHR. With help from the hospital’s information technology department, the PAST was developed into an electronic tool that was embedded into the organization’s documentation system; staff nurses could easily access and complete it.
Prior to study initiation, educational in-service sessions concerning palliative care and the PAST were provided to all nursing staff on the study unit. Microsoft PowerPoint® and poster presentations were used; the PowerPoint was available electronically, and the poster was displayed for the duration of the study. In addition, education about how to use the PAST, including information regarding documentation and how to enter interprofessional team review referrals, was provided at all staff meetings for all shifts. Minutes of the meetings were made available to those unable to attend the meeting in person, and one-on-one education was provided as needed. Information about the PAST was communicated to the hospitalist team (made up of inpatient physicians, nurse practitioners, and physician assistants) and to other inpatient providers, including surgeons and specialists, at an inpatient care committee meeting.
Each PAST was electronically signed by the RN who completed it, and reports of the completed PASTs were printed with the initials of the RN. During the study, the clinical nurse leader conducted daily chart audits to identify staff needing additional education regarding the PAST. Each PAST was reviewed for completeness and accuracy, and individualized education could be provided to RNs as needed. Ongoing hospitalist education was provided on a case-by-case basis.
Data for this study were analyzed using NCSS 2004. Study metrics were chosen following a review of the literature concerning palliative care needs of hospitalized patients, as well as interviews with staff nurses on the study unit regarding their greatest palliative care concerns for the patients. Data collected during the study phase included patient demographics, such as gender, marital status, length of stay, admitting problem, and underlying diagnosis (see Table 1). Major metrics of the study included symptom management (pain on admission and on discharge, nausea on admission and on discharge, shortness of breath on admission and on discharge), the number of palliative care consultations completed, and completion of advance directives.
The number of palliative care consultations among inpatients of the 24-bed medical-surgical oncology/orthopedic unit increased during the study phase; in the three months prior to the study, there were 94 palliative care consultations, compared to 126 palliative care consultations during the study phase.
Positive changes were also noted in regard to management of symptoms (see Table 2). Nausea decreased from 18% on admission to 2% on discharge, shortness of breath decreased from 27% on admission to 2% on discharge, and pain was reported as being an average of 4 of 10 on admission and an average of 1 of 10 on discharge, which represents a 75% improvement in pain from admission to discharge (0 is no pain and 10 is the worst pain). In addition, 59% of participants (26 of 44) had completed advance directives at discharge, which were incorporated into the EHR.
Two significant barriers to providing palliative care to seriously ill patients were addressed by this study. First, education about palliative care was provided to healthcare providers prior to study initiation, which helped them better understand the benefits of early palliative care intervention. Identifying which patients should receive palliative care discussions and deciding how early to begin these discussions is a significant part of improving palliative care. Advocating for the provision of palliative care to the critically ill maximizes benefits to patients and families (Naib, Lahewala, Arora, & Gidwani, 2015).
Second, this study addressed the creation and use of a tool for early identification of patients’ palliative care needs. During the study phase, the PAST was completed for 90% of patients either admitted or transferred to the study unit. The tool guided nurses in identifying potential palliative care needs of patients based on 10 criteria noted at admission or transfer of the patient to the study unit. Use of the PAST resulted in 44 nurse-driven palliative care consultation referrals in a 12-week period.
In a study that examined palliative care in intensive care units, Nelson et al. (2013) noted that using criteria to prompt referral for palliative care consultation appeared to help reduce the use of intensive care unit resources (although mortality rates remained the same) and increased the involvement of palliative care specialists for patients who were critically ill and their families. In addition, Nelson et al. (2013) determined that existing data and resources can be used to develop such criteria, which should be tailored for a particular intensive care unit, implemented through a process that involves key stakeholders, and evaluated appropriately.
The final phase of the current study involved evaluation of the PAST by observing specific metrics (i.e., management of nausea, shortness of breath, and pain and completion of advance directives). The authors determined that management of symptoms was, overall, improved among the study population. An increase in the completion of advance directives from admission to discharge was also found.
Some challenges were faced in the current study. For example, gaps in knowledge and the stigma of palliative care being only for the actively or imminently dying were addressed by providing education to bedside nurses and hospitalists at the beginning of and throughout the study period, as well as by offering continuing education, particularly to new nurses during orientation for new hires. Gaps in communication, such as those related to communication follow-through concerning the status of pending palliative care referrals, were overcome with additional documentation by the clinical nurse leader of the patient’s palliative status within the EHR.
This study represents a homogenous sample in one community hospital. Variation in admission diagnosis and in underlying conditions limits generalizability. Data gathering regarding palliative care deferral reasons began late, during week 8 of the study; therefore, these data are not included in this article. Finally, the study was conducted with one full-time palliative care provider (physician), one part-time nurse practitioner, and one clinical nurse educator with other roles within the institution. The study lacked a dedicated spiritual care provider.
Because this study focused on a medical-surgical setting, further studies are indicated for specialized hospital populations (e.g., intensive care unit, emergency department) and outpatient populations. Expansion of patient population criteria (e.g., patients with hip fractures aged 65 years or older, all patients aged older than 70 years who do not have advance directives) could also be explored. Measuring the quality of palliative care is critical for improving care, but no standard quality indicator exists (Dy et al., 2015). This could be an area for further study and improvement.
Education about palliative care provided to bedside nurses and other providers enhanced knowledge about the benefits of palliative care interventions for seriously ill patients. The PAST positively affected patients on the study unit through improved symptom management and timely completion of advance directives. With the built-in process of an interprofessional team review, nurses noted that physicians, nurse practitioners, and physician assistants seemed to have increased engagement regarding the palliative care plans of their patients.
The nurse-driven PAST supports improved patient access to timely and essential palliative care consultations, better symptom management, and increased completion of advance directives. In addition, the PAST is a interprofessional mechanism for nurses to become advocates for patients facing life-threatening illnesses. The PAST continues to be used on this medical-surgical oncology/orthopedic unit to advocate for the palliative care needs of seriously ill patients.
About the Author(s)
Colleen Flaherty, MSN, RN-BC, is a clinical nurse leader, Kristin Fox, ANP-BC, ACHPN, is an oncology and palliative care nurse practitioner, Donald McDonah, BSc, MD, CFP, FCFP, ABHPM, FAAHPM, HMDC, is the medical director of the palliative care program, and Jennifer Murphy, MSN, RN, OCN®, is the director of oncology services, all at Saint Joseph Hospital in Nashua, NH. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Flaherty can be reached at email@example.com, with copy to CJONEditor@ons.org. (Submitted April 2017. Accepted January 21, 2018.)
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