NURSES’ ROLES IN PALLIATIVE CARE CONVERSATIONS ON HF TEAMS

Abstract

Clinical guidelines encourage early discussion of palliative care (PC) for patients with advanced heart failure (HF). We undertook a constructivist grounded theory study of HF team experiences; the focus of this analysis was to explore nurses’ roles in communicating about PC with patients with advanced HF. Patients with NYHA Class III or IV were recruited at four study sites in three provinces. Patients and members they identified from their care team were interviewed. For each of 42 patients a team sampling unit (TSU) was created from 3-10 interviews. Analysis within and across TSUs was conducted using a constant comparative approach. PC communication was described as episodic and involving varying HF team members. Varied perceptions and expectations existed about nurses’ roles in initiating and conducting PC discussions. These were largely influenced by three interacting factors: nurses’ relationships with patients and their HF team; the structure of nursing work within a clinic/institution/regional system of HF care; nurses’ skill and comfort with PC conversations. Results suggest that the concept of ‘the palliative care conversation’ neither accurately represents actual practices nor ideally positions nurses to productively participate. Nurses are involved in many conversations that can incrementally contribute to early PC, including clarifying patient preferences and treatment goals, discussing self-care and responding to questions about information patients and families have received from physicians. Systems of care that promote consistency in nurse engagement on HF teams and recognize and improve nurses’ skills and comfort with PCrelated conversations will optimize conditions for meaningful, iterative PC conversations.