The role of the palliative care nurse consultant in promoting continuity of end-of-life care

Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review

BACKGROUND

While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied.

AIM

The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings.

DESIGN

We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924).

DATA SOURCES

We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018.

RESULTS

Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization.

CONCLUSION

Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.

The Role of Primary Care Physicians in Providing End-of-Life Care

BACKGROUND

Primary care physicians (PCPs) frequently have long-term relationships with patients as well as their families. As such they are well positioned to care for their patients at the end of their lives. As the number of patients in need of end-of-life care continues to grow, it is critical to understand how PCPs can fulfill that need. The purpose of our study is to perform a narrative review of the literature and develop a theoretical model delineating the overarching roles played by PCPs in caring for patients at the end of life.

METHODS

For this narrative review, the authors searched Medline (PubMed), Embase, Cochrane Library, and Scopus up to March 22, 2017. Articles were not limited by geography.

RESULTS

Review of existing literature generally supports 4 broad categories as the primary roles for PCP involvement in end of life: pain and symptom management; information management, including transmitting and clarifying information, setting care priorities, and assisting patients with treatment decisions; coordinating care and collaborating with other providers; and addressing patients' social, emotional, and spiritual needs.

CONCLUSIONS

Based on the results of this review, PCPs provide a wide range of services to patients at the end of life. Promoting the provision of the full scope of services by PCPs will help ensure improved continuity of care while providing the highest quality of care for patients, both in the United States and around the world.

Hospital Palliative Care Teams and Post-Acute Care in Nursing Facilities: An Integrative Review

Although palliative care consultation teams are common in U.S. hospitals, follow up and outcomes of consultations for frail older adults discharged to nursing facilities are unclear. To summarize and critique research on the care of patients discharged to nursing facilities following a hospital-based palliative care consult, a systematic search of PubMed, CINAHL, Ageline, and PsycINFO was conducted in February 2016. Data from the articles (N = 12) were abstracted and analyzed. The results of 12 articles reflecting research conducted in five countries are presented in narrative form. Two studies focused on nurse perceptions only, three described patient/family/caregiver experiences and needs, and seven described patient-focused outcomes. Collectively, these articles demonstrate that disruption in palliative care service on hospital discharge and nursing facility admission may result in high symptom burden, poor communication, and inadequate coordination of care. High mortality was also noted. [Res Gerontol Nurs. 2017; 10(1):25-34.].

Perspectives of Medical Specialists on Sharing Decisions in Cancer Care: A Qualitative Study Concerning Chemotherapy Decisions With Patients With Recurrent Glioblastoma

BACKGROUND

In cancer care, difficult decisions concerning advanced treatment need to be made, weighing possible life prolongation against harmful side effects. Treatment is frequently started, showing the need to explore how decisions are made. Little is known about the perspectives of physicians on sharing decision making with patients. This qualitative study aimed to describe the perspectives of medical specialists on the decision-making process with patients with glioblastoma concerning starting new treatment.

METHODS

Qualitative interviews were held with medical specialists. One focus group was organized with medical professionals. Their opinions about elements of shared decision making and the applicability in the context of patients with glioblastoma were assessed. The topic list for the focus group was based on the analysis of the interviews. Qualitative analysis of the transcripts was performed by three researchers independently.

RESULTS

Medical specialists considered shared decision making to be important; however, they did not adhere to its elements. Stopping treatment was not considered equal to continuing treatment. Exploration of the patients' wishes was done implicitly, and shared responsibility for the decision was not highly recognized. The main barriers to shared decision making were preferences of both patients and specialists for starting or continuing treatment and assumptions of physicians about knowing what patients want.

CONCLUSION

Medical specialists recognized the importance of patient involvement but experienced difficulty in sharing decision making in practice. Elements of shared decision making are partly followed but do not guide decision making. To improve cancer care, education of medical specialists and adjustment to the elements are needed to involve patients.

Nurses' perspectives on the discharge of cancer patients with palliative care needs from a gastroenterology ward

BACKGROUND

People with cancer usually like to spend as much time as possible at home rather than in the hospital. Nurses have a pivotal role when patients are discharged to a unit in hospital or from hospital to the community health-care system.

AIM

To explore how frontline surgical nurses assess patients with gastrointestinal cancer receiving palliative care and the implications of their assessment and competency for the patients' discharge destinations.

METHODS

A descriptive exploratory approach was used involving focus group interviews with a purposive sample of ten nurses from an inpatient gastroenterology surgical ward at a university hospital in Norway. Transcriptions of the interviews were analysed using Kvale and Brinkman's thematic approach.

RESULTS

Two overall themes emerged that had implications for the nurses' recommendations for optimal patient follow-up care after discharge: 'the complexity of and fluctuations in the patients' health status' and 'considering the competency of the nurses at the discharge destinations'.

CONCLUSIONS

This study illustrates surgical nurses' perspectives on the discharge destinations of cancer patients receiving palliative care. The findings have implications for initiatives aimed at providing more home-based palliative care.

Advanced nursing roles: a systematic review

In this systematic literature review, we analyzed and synthesized the literature on one specialized advance practice nursing role in three countries for the purpose of describing and comparing these roles, as well as discussing whether an international consensus of the advance practice nursing definition is possible. A systematic search on CINAHL and PubMed Medline was conducted in 2011 to search the literature on the nurse consultant in the UK, the clinical nurse specialist in the USA, and the clinical nurse consultant in Australia. The studies (n = 42) were analyzed and combined using qualitative content analysis method. The roles of the nurse consultant, clinical nurse specialist, and clinical nurse consultant were similar. The variation in the roles appears to derive from organizational or individual choices, not the country in question. The study process comprised a synthesized representation of one specialized advance practice nursing role. More work is needed to further define the concept of the advance practice nursing, as well as its implementation on other cultures beyond this review. Based on this review, an international consensus regarding the definition of advance practice nursing and its subroles is possible.

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

BACKGROUND

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers.

AIM

To explore factors that support partnership working between specialist and generalist palliative care providers.

DESIGN

Systematic review.

METHOD

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

RESULTS

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

CONCLUSION

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.

An exploration of personal initiative theory in the role of consultant nurses

The aim in this paper is to investigate the contribution personal initiative theory makes in understanding the consultant nurse role. The role was introduced in the UK in 2000 to improve patient outcomes, clinical leadership and retention of experienced clinicians. A larger study used a multi-method approach to collect quantitative and qualitative data from focus groups, interviews and a questionnaire administered nationally at two time points. Findings from longitudinal telephone interviews with 30 consultant nurses are the focus of this paper.

Three consultant nurses were selected as case studies to examine the potential of personal initiative theory when applied to new nursing roles. The activities of two of the three demonstrated a high level of personal initiative in the job. They persisted in overcoming problems faced in improving practice. The third scored lower: she emerged as a reactive conformist and less likely than the other two to pursue initiatives of her own.

Personal initiative theory has potential as a framework for evaluating the consultant nurse role, although further research is needed to test it. The longitudinal analysis revealed a determination to stay in the job and overcome difficult challenges when consultants show initiative and are making progress in achieving change.

Multiple evaluation of a hospital-based palliative care consultation team in a university hospital: Activities, patient outcome, and referring staff's view

Objective:

Although the number of hospital-based palliative care consultation teams (PCCTs) is rapidly increasing in Japan, there is limited information available concerning the activities and usefulness of PCCT in the country. The aim of this study is to clarify the activities, patient outcome, and referring staff's view of an established PCCT in Japan.

Method:

This was a prospective study to follow patients referred to a PCCT for 28 days over a 1-year period. Patients were assessed by the Support Team Assessment Schedule–Japanese version (STAS-J) and EORTC QLQ C-30 at the time of referral and on days 7, 14, and 28. A staff survey was implemented using a questionnaire after each observation period.

Results:

Of 180 patients referred, 53 patients were eligible for the study. Although the median of the number of the reasons for referral was 1, the PCCT provided several kinds of support: pain management, 94%; emotional support for the patient, 49%; and emotional support for the family, 36%. On day 7 after referral, of the items of STAS-J and the EORTC QLQ C-30 subscales, only insomnia improved significant whereas “other physical symptoms” and constipation were significantly exacerbated. In the staff survey, of the 98 respondents, more than 90% considered the effect of the PCCT as “excellent” or “good” and were satisfied with the support provided.

Significance of results:

This study showed that the PCCT performed comprehensive assessments on referred patients and provided extra support. No patient's QOL 1 week after referral was improved with the exception of insomnia. Referring staff highly evaluated the activities of the PCCT. In the evaluation of PCCTs, further research about the variation of clinical activities of PCCTs, their applicability, and benefit is needed.

The palliative care clinical nurse consultant: an essential link

This study describes the role of acute hospital palliative care nurse consultants and makes recommendations about future directions for the role development of this role. While the palliative care nurse consultant role is accepted in the acute setting there is little evidence or literature about what contributes to the success of this role. A three-phase study was undertaken to describe the role of palliative care nurse consultants in acute hospitals in Melbourne, Australia. The first phase of the three-phase study, involving in-depth qualitative interviews with the palliative care nurse consultants, is reported in this article. Using open-ended semi-structured questions, 10 palliative care nurse consultants were interviewed using open-ended questions about aspects of their role and the interviews were thematically analysed. Four main themes were identified that clarified the role; being the internal link; being the lynch pin; being responsive and being challenged. The palliative care nurse consultants were the first point of introduction to palliative care and thus they saw a significant role in introducing the concept of palliative care to those requiring palliative care, their families and others. They are an important link between the settings of care required by people accessing palliative care-acute, in-patient palliative care and community care. The palliative care nurse consultants saw themselves in leadership positions that in some ways defy boundaries, because of the inherent complexity and diversity of the role. The palliative care nurse consultants' role appears to be pivotal in providing expert advice to staff and people requiring palliative care, and connecting palliative care services both within the hospital and to external services.

Palliative care nurse consultants in Melbourne: a snapshot of their clinical role

AIM

The current role of the palliative care nurse consultant (PCNC) is as diverse as the organisations in which such nurses work. This study reports on Phase 2 of a larger study in Melbourne, Australia, which focused particularly on describing some of the clinical aspects of the work of the PCNC in the acute hospital setting.

DESIGN

A cross-sectional survey was used to describe the selected clinical activities of the PCNC.A data collection sheet was developed to gather information about their work.

SAMPLE AND SETTING

21 PCNCs participated in the study and data were collected for 282 patients within 12 acute hospitals in Melbourne.

METHODS

PCNCs recorded selected information about their clinical work for a two-week period. Descriptive analyses were carried out to calculate frequency distributions and mean scores.

FINDINGS

In 73% of referrals, the PCNC was the first contact the patient had with any palliative care health professional; patients with a malignant diagnosis constituted the main workload of the PCNC; the highest number of interventions was recorded for the symptom management/psychosocial care category; and the time from acute hospital admission to PCNC consult referral was 6.57 days.

CONCLUSIONS

This study has demonstrated that the work of PCNCs is complex and diverse. This research forms the basis for further study into the role of the PCNC.