Palliative Nurses Association Research Articles

Measuring What Matters: Top-Ranked Quality Indicators for Hospice and Palliative Care From the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association

ContextMeasuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. ObjectivesThe Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. MethodsThe MWM process was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. ResultsWe narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, and Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. ConclusionThis consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. settings. Further development will assemble implementation tools for quality measurement and benchmarking.

Ethical Issues Experienced by Hospice and Palliative Nurses

Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospic

Translating Evidence into Practice at the End-of-Life: Information needs, access and usage by hospice and palliative nurses.

Information literacy is important for evidence-based nursing and quality patient care. Hospice/palliative nurses are often unaffiliated with academic institutions and may experience barriers accessing information. The project's goals were to identify their (1) access to evidence-based resources, (2) information literacy skills and (3) training needs. The research design was a descriptive assessment. Members of the Hospice & Palliative Nurses Association in 4 states received the assessment in collaboration with University of Pittsburgh. The methodology yielded statistics on information needs, access and literacy skills. Data analysis included frequency distributions, cross-tabulations, and a chi-square test. Of the respondents, 69% worked clinically. The need for drug or disease information occurred in 89% to 100% of respondents across sites. Respondents knew of PubMed in 28% to 70% of sites. Evidence databases were unavailable in 7% to 39% of settings. The most frequent source of information was colleagues (74%), followed by Internet searches (70%). About 43% of respondents felt confident using health literacy strategies. The greatest training needs were finding quality nursing information (79%), reliable patient education (65%) and evidence for practice/quality improvement (64%). There is a large need for quality nursing, patient and evidence-based information in hospice environments. Hospice nurses access the Internet, although evidence/database access is often lacking or unknown making it suboptimal.

The Relationship of Patient Population and Nurses Certification Status on Nurses' Practices in Preparing Families for the End of Life.

While nurses usually prepare family for the patients' final days, little is known about how this is done. The purpose of this study was to describe nurses' beliefs and practices concerning family preparation for dying, focusing on strategies, tailoring, timing and content of preparation. Nurses' preparatory practices were compared by patient population (hospice or palliative care) and the nurses' certification status. A descriptive, comparative survey was conducted. All RN members of the Hospice and Palliative Nurses Association and who met the inclusion criteria (N=2706) were invited and 1434 (53.1%) participated. Nurses believe families can be prepared, and identified trust and repetition as important strategies. There are significant differences based on population regarding nurses' beliefs about preparation, strategies, tailoring, timing and content. Tailoring differed based on certification status. This information can be compared to what is known about family preparatory needs to develop preparatory interventions that are tailored to patient and family characteristics. Revisiting the similarities and differences in the practice of nurses in hospice and palliative care is important as the specialty continues to mature to assure that adequate education and proper criteria for certification are being provided for all hospice and palliative care nurses.

Palliative Sedation: An Analysis of International Guidelines and Position Statements.

To describe the suggested clinical practice of palliative sedation as it is presented in the literature and discuss available guidelines for its use. CINAHL, PubMed, and Web of Science were searched for publications since 1997 for recommended guidelines and position statements on palliative sedation as well as data on its provision. Keywords included palliative sedation, terminal sedation, guidelines, United States, and end of life. Inclusion criteria were palliative sedation policies, frameworks, guidelines, or discussion of its practice, general or oncology patient population, performance of the intervention in an inpatient unit, for humans, and in English. Exclusion criteria were palliative sedation in children, acute illness, procedural, or burns, and predominantly ethical discussions. Guidelines were published by American College of Physicians-American Society of Internal Medicine (2000), Hospice and Palliative Nurses Association (2003), American Academy of Hospice and Palliative Medicine (2006), American Medical Association (2008), Royal Dutch Medical Association (2009), European Association for Palliative Care (2009), National Hospice and Palliative Care Organization (2010), and National Comprehensive Cancer Network (2012). Variances throughout guidelines include definitions of the practice, indications for its use, continuation of life-prolonging therapies, medications used, and timing/prognosis. The development and implementation of institutional-based guidelines with clear stance on the discussed variances is necessary for consistency in practice. Data on provision of palliative sedation after implementation of guidelines needs to be collected and disseminated for a better understanding of the current practice in the United States.

Heart Failure Boot Camp: Developing a Better Understanding of the Disease and Creating Effective Palliative Strategies for Management (P4)

4. Identify strategies to initiate and develop palliative care programs across healthcare settings to promote continuity of care and integrated palliative care services. 5. Review physical and psychological symptoms associated with advanced illness and discuss pharmacological and non-pharmacological interventions. 6. Utilize educational methods consistent with patients’ and families’ preferred mode of learning to promote understanding of serious or life-threatening illness, treatment options, management, and supportive resources. The Hospice and Palliative Nurses Association supports nurses seeking advancement of their professional development and career with specialty certification. This 1-day course encompasses the fundamental concepts of palliative nursing. The review course will provide a review of the content areas based on the NBCHPN detailed test content outline. This course may be used to increase the hospice and palliative nurse’s knowledge of general palliative nursing or to assist the nurse in self-identifying topics that require further preparation and study in advance of sitting for the specialty certification examination. Note: Participation in a review course does not guarantee successful completion of a certification test. CEs7.5 Contact Hours/4.5 designated pharmacology hours The Hospice and Palliative Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Required materials: APRN Certification Preparation Coursed Advanced Practice Nurse Core Curriculum for the Advanced Practice Nurse ACHPN Candidate Handbook e available for print for free from the NBCHPN website

New Palliative Care Guidelines Stress Certification, Diversity

New Palliative Care Guidelines Stress Certification, Diversity

Competence Clarified (304)

1.Distinguish between competence and competency.2.Identify the beliefs which underpin the definition of continuing competence.3.State a definition of continuing competence which can clarify continuing competence in the practice hospice and palliative care. This session presents the work of a task force appointed by the National Board for Certification of Hospice and Palliative Nurses (NBCHPN). The task force examined the concept of competence and continuing competence. The task force clarified these concepts to guide the certification and recertification process and requirements for NBCHPN certificants who include advanced practice registered nurses (APRNs), registered nurses (RNs), licensed practical/vocational nurses (LPNs, LVNs), nursing assistants, and administrators. The task force distinguished between competence and competency, delineated its beliefs about competence, and defined continuing competence. The task force included membership from outside of NBCHPN: the deputy director of the American Board of Nurse Specialties (ABNS) and the editor of the Journal for Continuing Education in Nursing: Continuing Competence for the Future. The task force culminated its work in “The Statement on Continuing Competence for Nursing.” The Statement includes a crosswalk between core competencies set forth in Nursing: Scope and Standards of Practice (American Nurses Association, 2010) and the Hospice and Palliative Nurses Association (HPNA)’s Competence Topics for RNs and APRNs. In partnership with the American Board of Nurse Specialties (ABNS) and Accreditation Board for Specialty Nursing Certification (ABNSC), the task force continues to explore uses of its Statement to further the ABNS Research Agenda, ABNS success markers, refinement of certification and recertification requirements, and other endeavors. This presentation describes the process that the task force employed and the product which it produced. The process included an extensive literature review and structured discussions during web-enhanced conference calls. The presentation invites dialogue about the use of the Statement in defining credentialing criteria and in exploring the concept of continuing competence in the practice of hospice and palliative care.

Hospice and Palliative Nurses Association Announces Advanced Practice Mentoring Program

Hospice and Palliative Nurses Association Announces Advanced Practice Mentoring Program

The HPNA Research Agenda for 2009-2012

The research committee of the Hospice and Palliative Nurses Association engaged in an iterative process to develop a research agenda for the association that is expected to provide a focus for graduate students and junior and senior researchers and guide our organization's research funding. In addition, this agenda will illustrate to stakeholders the importance of these research foci. The focus of this article is twofold: to describe the process for developing the agenda and describe the agenda itself with rationale for the foci.

Networking Opens Doors for Palliative Care, Say Doctors in Rural Practices

Networking Opens Doors for Palliative Care, Say Doctors in Rural Practices

Consider Palliative Care Options for Patients With ESRD

Kerri Wachter is a senior writer with Elsevier Global Medical News. TAMPA — Patients with end-stage renal disease are good candidates for palliative care and hospice, but many are not referred, according to Dr. Alvin H. Moss. “Nephrologists, by nature, are not inclined toward talking about end-of-life care” and are not trained to deal with it, said Dr. Moss, director of the palliative care service in the nephrology section of West Virginia University, Morgantown. Patients with end-stage renal disease tend to be old with short life expectancies, and they typically have multiple comorbidities and a high symptom burden, Dr. Moss said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. Most patients on hemodialysis are older than age 65. Of the estimated 85,000 patients on dialysis who die each year, 20%–25% die after choosing to stop dialysis. The 1-year survival rate for dialysis patients is 78%; the 5-year rate is 32%,” he said. Patients on dialysis have an average of nine symptoms, which may include dry skin, fatigue, itching, bone and joint pain, and muscle cramps. Also, half of dialysis patients report pain (J. Am. Soc. Nephrol. 2005;16:2487–94). “The symptom burden is similar for dialysis patients as for cancer patients,” Dr. Moss said. Predictors of poor prognosis for patients with end-stage renal disease include greater age, reduced functional ability, poor nutritional status, and the presence of comorbid illness, Dr. Moss said. “If a patient has severely impaired functional status, it confers a 3.5-fold greater risk of early mortality,” Dr. Moss said. “If the patient is not independent in activities of daily living … we're talking about a significantly increased risk of early death.” Nephrologists are often unsure about which patients to refer for palliative care. “I teach them to ask themselves on rounds, ‘Would I be surprised if this patient died in the next month?’ It takes about 10 seconds,” Dr. Moss said. If the answer is no, the patient is a good candidate for palliative care. “That question turns out to predict those patients who have greater comorbidities, greater pain scores, lower functional status, lower serum albumin levels, and a greatly increased risk of being dead within a year.” In one study, Dr. Moss asked nephrology nurse practitioners to answer this question with regard to their patients. The nurse practitioners indicated that they would not be surprised regarding 22% of patients. One year later, those in the “no” group had a 2.74-fold increased risk of death, compared with those in the “yes” group. “Pain is a very common and severe symptom. … Usually it's the most severe symptom that dialysis patients report,” Dr. Moss said. In one study, pain was undertreated in about three-quarters of dialysis patients (Am. J. Kidney Dis. 2003;42:1239–47). In his own study of 143 dialysis patients, 54% reported pain. Of those who reported pain, 16 were already being treated for pain and 17 refused treatment. Those remaining were treated for pain using the World Health Organization Analgesic ladder (J. Am. Soc. Nephrol. 2006;17:3198–203). Of the 45 patients who completed pre- and posttreatment evaluations, 31% had neuropathic pain, 40% had nociceptive pain, and 29% had both types. Treatment using the analgesic ladder worked equally well for neuropathic and nociceptive pain. Many opioids are renally excreted, so a few precautions are needed when choosing a pain medication for patients with end-stage renal disease, Dr. Moss said. “Because of problems with renal excretion, we have to look at which ones are safe, which ones you might want to use with caution … and which drugs not to use.” Pain medications that are considered safe and effective in this population include fentanyl, methadone, hydromorphone, acetaminophen, gabapentin, and pregabalin. Avoid codeine, meperidine, morphine, and propoxyphene, because the renally excreted active metabolites can accumulate and cause opioid neurotoxicity. “If we're teaching evidence-based medicine, we know there's a higher risk for complications using these pain medications in dialysis patients. … We should use medications that are safer,” he said. Caution should be used in prescribing hydrocodone, oxycodone, tramadol, desipramine, and nortriptyline. These drugs have been reported to be safely used in dialysis patients, but the data on pharmacokinetics are insufficient to conclude that these drugs are safe in this population. AMDA has two resources that could help long-term care medical directors and staff care for residents near death with renal disease: ▸ “Palliative Care in the Long-Term Care Setting” is available at www.amda.com/resources/whatsnew.cfm#palliativecare. ▸ “Clinical Corner: Chronic Kidney Disease” can be found at www.amda.com/tools/clinical/ckd.cfm.

Treat Nonmotor Symptoms in Parkinson's Patients With Advanced Disease

Kerri Wachter is a senior writer with Elsevier Global Medical News. TAMPA — Eventually, all patients with Parkinson's disease are candidates for palliative care, but advanced treatment planning, especially for nonmotor symptoms, isn't always discussed with these patients or their families, Dr. Neal E. Slatkin said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. When patients are midway through the progression of Parkinson's disease (PD), “this is time for advanced treatment planning. This is the time to begin to have those difficult discussions with the patients and their families and to make the decisions that need to be made,” said Dr. Slatkin, director of supportive care, pain, and palliative medicine at City of Hope National Medical Center in Arcadia, Calif. In advanced PD, patients may have multiple nonmotor symptoms, such as cognitive impairment, in addition to advanced motor symptoms. Roughly a third of patients report that the nonmotor symptoms affect their quality of life more than the motor symptoms, said Dr. Slatkin, adding that researchers are beginning to recognize that the nonmotor symptoms are just as common and important as are any other PD symptoms. Neuropsychiatric problems are fairly common among patients with advanced PD. Depression occurs in almost 40% of patients, hallucinations (mostly visual) in almost 30%, cognitive impairment in almost 40%, and anxiety in 20%. Risk factors for depression in PD patients include a history of depression, cognitive impairment, and akinetic/rigid type disease. Recognizing and treating depression “truly can be lifesaving for some patients,” said Dr. Slatkin. Doctors who assess and treat PD patients for depression should ask each patient how he or she thinks the drug is working, said Dr. Slatkin. There are many antidepressants available, and for any particular patient, some work better than others. Dr. Slatkin said that sertraline (Zoloft) is probably not a good choice for patients with PD and depression because, in addition to being a selective serotonin reuptake inhibitor, it also is a dopamine reuptake inhibitor that could potentially worsen PD symptoms. Hallucinations, especially visual ones, are common in advanced PD, occurring in roughly 30% of people in this stage. “The important thing to think about with hallucinations in [PD] is that you don't necessarily have to treat them,” said Dr. Slatkin. If the hallucinations are not alarming to the patient, Dr. Slatkin's advice was to hold back on therapy. Hallucinations often are more troubling to caregivers and staff than they are to elderly patients. When psychosis appears, it's important to rule out other factors, such as medications or infection, that could be to blame. For example, anticholinergic medications are associated with psychosis/delirium in PD patients. Other medications that can be associated with psychosis include monoamine oxidase-b inhibitors, dopamine agonists, and catechol O-methyltransferase inhibitors. Given this, it may be desirable to compromise motor function to preserve cognitive function in some people with PD. “That's when we start to eliminate some of the Parkinson's medications,” said Dr. Slatkin. Of the antipsychotics, clozapine should be the first choice because it has been shown to be highly effective in treating psychosis in patients with PD, said Dr. Slatkin. He recommended starting with the lowest dose possible. “We start people at 6.25 mg” used in the morning or twice a day. Quetiapine would be a good second choice because it improves psychosis without exacerbating motor symptoms, he added. In 2005, the Food and Drug Administration ordered manufacturers of atypical antipsychotics, including clozapine and quetiapine, to add a new black-box warning that the drugs are associated with an increased risk of death related to psychosis and behavioral problems in elderly patients with dementia. Some evidence suggests that cholinesterase inhibitors, including donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl), may have potential benefits for PD dementia, though they can induce nausea and weight loss. Dr. Slatkin said that he recommends morning dosing of these drugs. Dr. Slatkin disclosed that he had no potential conflicts of interest.

Abstracts from The Annual Assembly of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association

Abstracts from The Annual Assembly of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association

Hospice and Palliative Nurses Association Members Provide Disaster Relief Nursing Care to Katrina Victims

Hospice and Palliative Nurses Association Members Provide Disaster Relief Nursing Care to Katrina Victims

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

Voluntary consensus care standards

8073 Background: The National Consensus Project for Quality Palliative Care (NCP) is a groundbreaking initiative which originated in 2001 that aims to improve the delivery of palliative care in the United States. The NCP is a response to the need for uniformly accepted definitions of the essential elements and best practices in palliative care in order to create voluntary consensus Clinical Practice Guidelines for the establishment and development of clinical palliative care programs across the United States. Methods: To remedy this situation and improve delivery of palliative care in the United States, Voluntary Consensus Standards for Palliative Care were developed by the (NCP) and were released in January 2004. The NCP is a consortium of 5 national palliative care organizations including American Academy of Hospice and Palliative Medicine, Center to Advance Palliative Care, Hospice and Palliative Nurses Association, National Hospice and Palliative Care Organization and Partnership for Caring. A Steerin...

The American Society of Pain Management Nurses practice analysis: Role delineation study

A role delineation study was carried out by the American Society of Pain Management Nurses (ASPMN) to determine the activities performed by nurses involved in pain management. Demographic characteristics of pain management nurses and differences in practice based on educational preparation and specialty affiliation were identified. The role delineation survey was developed based on Nursing Intervention Classifications. The survey consisted of 91 activity statements. Respondents rated the frequency of performing each activity and the importance of the activity. A Mean Activity Index score was calculated for each item. All members of the ASPMN, the nursing special interest group (SIG) of the American Pain Society, and the pain SIG of the Oncology Nursing Society, as well as random samples of members of the National Association of Orthopaedic Nurses, Hospice and Palliative Nurses Association, American Association of Nurse Anesthetists, American Association of Critical Care Nurses, and American Academy of Nurse Practitioners were surveyed. Seven hundred and sixty-one questionnaires were analyzed (24.8% response rate). Demographic characteristics of the sample mirrored those of nursing as a whole in the United States. The activities with the highest Mean Activity Index were primarily those involving assessment of pain. Nurses with diploma and Associate Degree preparation rated assessment and nonpharmacologic management higher and communication and collaboration lower than nurses with higher educational preparation. Activities varied somewhat as a reflection of respondents' nursing specialty. The results of the study will be used to refine standards of care, develop nursing education curricula, develop research priorities, and develop a blueprint for a certification examination in pain management nursing. © 2002 by the American Society of Pain Management Nurses

First Joint Hospice and Palliative Clinical Conference a Success!

Hospice and Palliative Nurses Association, 211 North Whitfield Street, Suite 375, Pittsburgh, Pennsylvania 15206-3031, (412) 361-2470; fax: (412) 361-2425, Internet: http://www.HPNA.org Editor’s Note: I am pleased to announce the journal’s new relationship with the Hospice and Palliative Nurses Association (HPNA). Beginning with this issue, the column, HPNA News, will appear at least quarterly to share information and activities of this wonderful nursing organization with the readers ofHHN.We have also increased the number of articles and departments that focus on palliative care and end-of-life issues, which are of great importance to home care and hospice nurses. The journal’s mission remains focused on publishing material that meets the educational and information needs of practicing home care and hospice nurses. I encourage you to learn more about this important organization and its certification program by contacting them and reading their columns.