Last week a physician colleague expressed her concern about signing routine hospice admission orders for her elderly patient with end stage heart failure. The routine ‘as needed’ (PRN) orders included phenobarbital, pentobarbital, haloperidol, lorazepam, and morphine. “The hospice nurses know more about this than I do, don’t they?” she said. Yesterday, a longtime palliative care nurse told me she didn’t want to put her mother with end stage heart failure in a nursing home with hospice, because “they’ll just give her morphine and ativan. I want her heart failure managed.”
I worked as a hospice case manager in the community for eight years prior to becoming a nurse practitioner (NP) and have blogged in the past here about similar concerns. In my experience, most hospice nurses know a lot more about how to manage generic end of life physical symptoms than many physicians, particularly pain management and psychosocial symptoms/issues. Highlight generic. Physicians and NPs are trained to think pathophysiologically. We think via differential diagnosis. For example, as a hospice nurse (RN), I might have managed shortness of breath (SOB) in a patient with heart failure with low dose morphine. As an NP I might also look for subtle signs of fluid overload (JVD, bibasilar crackles, dependent edema) for possible diuretic adjustment and think about how the patient’s renal function might factor into these decisions. I might check if there are co-morbidities to consider (aortic stenosis, atrial fibrillation, myelodysplasitic syndrome/chronic anemia, COPD, Parkinson’s, anxiety, GI dysmotility) when thinking about meds (including opioids) in determining the source and treatment for the SOB. As an RN, if a patient became confused I would check for pain, constipation, and urinary retention. But then what? I might give lorazepam or haldol. These are likely pre-signed orders that may even be in the home for those “just in case” times. Convenient. As an NP, I might also think about infection, co-morbidities, polypharmacy, and medication side effects (particularly in the elderly.
Registered nurses are trained to alleviate suffering through diagnosis and treatment of human responses to actual or potential illness. We are trained to assess and treat based on holistic goals and to view the patient in the context of their defined family. Palliative care and nursing philosophy share a holistic approach to care that encompasses physical, emotional and spiritual concerns of the patient and family unit. It is no small wonder that nurses have been the foundation of community hospice work since its beginnings. Physicians are trained to formulate and treat medical diagnoses. Nurse Practitioners are, well, the middle children. We are nurses who have advanced training in diagnosis and treatment of medical conditions in addition to our foundational training. Our medical training is not as deep or broad as that of physicians. Nurse practitioners often pursue further training to develop an area of expertise.
None of us truly knows what we don’t know. Even the most experienced hospice nurses don’t know how their practice would differ if they had the advanced education and training of a nurse practitioner. Few physicians or physician assistants understand the level of training of RNs or LVNs/LPNs, nor their scope of practice. How could they? They’re not nurses. Only the nurse practitioner holds the dual training and, as such, is the perfect liaison for optimal collaboration between these two disciplines.
Surprisingly, nurse practitioners do not play a pivotal role in most community hospice agencies. Medicare requires that there be a physician medical director. Registered nurses usually function as the hospice case manager for the care of the end stage illness.
Hospice nurses are well trained in using medications to manage symptoms. Hence the array of the (all too often) ‘one size fits all’ order set of PRNs. This makes sense when the nurse is out in the home or on the phone doing her/his very best to assess and treat distressing symptoms at the end of life. It’s pretty difficult to track down the doctor of record, contact her/him, describe the situation, request an order and get it to the patient within a reasonable period of time such that the patient (and family) does not suffer for hours longer. Having pre-signed orders to use PRN can be a life-saver (no pun intended) at times. The downfall is the one size fits all practice. Shortness of breath equals morphine; anxiety equals lorazepam; confusion/agitation equals haldol.
There is continued grumbling among hospices and palliative care folks that patients are often referred too late to hospice care. However, at least in the case of patients with some non-cancer diagnoses, are they? Is our system set up to care for these patients optimally at the end of life? Sadly, I think not.
Happily, there is a relatively easy solution – use nurse practitioners who have advanced training in palliative care and (my bias) gerontology.
What if hospice nurses had easy access to a palliative care NP who had the training to assess and treat medically complex patients at the end of life? What if the hospice nurses had access to someone who understood their practice and could provide the appropriate education and support to improve their practice? What if the NP was available for home visits? Hospice nurses might practice differently. Patients would get better care. And health care providers might not be so reticent to refer their patients a little earlier.
The Medicare Hospice Benefit requires the provision of 24-hour nursing services and a physician medical director who reviews medical orders and participates in an interdisciplinary team group overseeing patient care. Why not a nurse practitioner and physician as co-directors? It makes sense. It’s time. And it’s the right thing to do.
I worked as a hospice case manager in the community for eight years prior to becoming a nurse practitioner (NP) and have blogged in the past here about similar concerns. In my experience, most hospice nurses know a lot more about how to manage generic end of life physical symptoms than many physicians, particularly pain management and psychosocial symptoms/issues. Highlight generic. Physicians and NPs are trained to think pathophysiologically. We think via differential diagnosis. For example, as a hospice nurse (RN), I might have managed shortness of breath (SOB) in a patient with heart failure with low dose morphine. As an NP I might also look for subtle signs of fluid overload (JVD, bibasilar crackles, dependent edema) for possible diuretic adjustment and think about how the patient’s renal function might factor into these decisions. I might check if there are co-morbidities to consider (aortic stenosis, atrial fibrillation, myelodysplasitic syndrome/chronic anemia, COPD, Parkinson’s, anxiety, GI dysmotility) when thinking about meds (including opioids) in determining the source and treatment for the SOB. As an RN, if a patient became confused I would check for pain, constipation, and urinary retention. But then what? I might give lorazepam or haldol. These are likely pre-signed orders that may even be in the home for those “just in case” times. Convenient. As an NP, I might also think about infection, co-morbidities, polypharmacy, and medication side effects (particularly in the elderly.
Registered nurses are trained to alleviate suffering through diagnosis and treatment of human responses to actual or potential illness. We are trained to assess and treat based on holistic goals and to view the patient in the context of their defined family. Palliative care and nursing philosophy share a holistic approach to care that encompasses physical, emotional and spiritual concerns of the patient and family unit. It is no small wonder that nurses have been the foundation of community hospice work since its beginnings. Physicians are trained to formulate and treat medical diagnoses. Nurse Practitioners are, well, the middle children. We are nurses who have advanced training in diagnosis and treatment of medical conditions in addition to our foundational training. Our medical training is not as deep or broad as that of physicians. Nurse practitioners often pursue further training to develop an area of expertise.
None of us truly knows what we don’t know. Even the most experienced hospice nurses don’t know how their practice would differ if they had the advanced education and training of a nurse practitioner. Few physicians or physician assistants understand the level of training of RNs or LVNs/LPNs, nor their scope of practice. How could they? They’re not nurses. Only the nurse practitioner holds the dual training and, as such, is the perfect liaison for optimal collaboration between these two disciplines.
Surprisingly, nurse practitioners do not play a pivotal role in most community hospice agencies. Medicare requires that there be a physician medical director. Registered nurses usually function as the hospice case manager for the care of the end stage illness.
Hospice nurses are well trained in using medications to manage symptoms. Hence the array of the (all too often) ‘one size fits all’ order set of PRNs. This makes sense when the nurse is out in the home or on the phone doing her/his very best to assess and treat distressing symptoms at the end of life. It’s pretty difficult to track down the doctor of record, contact her/him, describe the situation, request an order and get it to the patient within a reasonable period of time such that the patient (and family) does not suffer for hours longer. Having pre-signed orders to use PRN can be a life-saver (no pun intended) at times. The downfall is the one size fits all practice. Shortness of breath equals morphine; anxiety equals lorazepam; confusion/agitation equals haldol.
There is continued grumbling among hospices and palliative care folks that patients are often referred too late to hospice care. However, at least in the case of patients with some non-cancer diagnoses, are they? Is our system set up to care for these patients optimally at the end of life? Sadly, I think not.
Happily, there is a relatively easy solution – use nurse practitioners who have advanced training in palliative care and (my bias) gerontology.
What if hospice nurses had easy access to a palliative care NP who had the training to assess and treat medically complex patients at the end of life? What if the hospice nurses had access to someone who understood their practice and could provide the appropriate education and support to improve their practice? What if the NP was available for home visits? Hospice nurses might practice differently. Patients would get better care. And health care providers might not be so reticent to refer their patients a little earlier.
The Medicare Hospice Benefit requires the provision of 24-hour nursing services and a physician medical director who reviews medical orders and participates in an interdisciplinary team group overseeing patient care. Why not a nurse practitioner and physician as co-directors? It makes sense. It’s time. And it’s the right thing to do.
Comments
It makes pretty good sense to me that adding some type of post-discharge follow-up support would help with these abysmal stats. This can be with hospice care, AIM programs, or some other hybrid. Should NP's be involved - absolutely. The biggest problem that I see is that physicians are not often involved in their patients care once they are admitted to hospice care. NP's can act as a bridge to improve the quality of care for patients with complex medical conditions.
courageous to have written such a piece and agree wholeheartedly with
your sentiment. I am sure it will stir up some controversy
particularly from hospice nurses and maybe the unlightened MD who may
not have been exposed to NP's. I especially liked your points about
hospice care being a little too generic (something that used to worry
me when I was a hospice nurse) and "none of us truly knows what we
dont know......hospice nurses ..how practice would differ if they had
received NP education"
Hospices should welcome your suggestions in several aspects in that it
may afford the patient better symptom control, enhance the publics
opinion of hospice (particularly those who claim that all hospice does
is "give morphine and help the pt to die") and also could keep pts on
the program longer for revenue.
Just to play devils advocate a little bit, I do think there is value to a philosophy of care that masks symptoms until a patient dies, rather than working them up. SOB in CHF is a great example of where masking the symptom with morphine is likely not the best approach. "Terminal delirium" on the other hand is perhaps a little different. I suspect that many episodes of "terminal delirium" would be reversible in the short term if each of the many factors causing the delirium were addressed (O2, sodium, dehydration, renal failure). Perhaps a model of care where we are comfortable ignoring the many underlying factors and instead use large doses of symptom medications (antipsychotics in this case) is the best approach.
That said, I would vote for NPs to lead the way! (just as long as they weren't completely wrapped up in the traditional medical model).
Yes, the system needs to change. Change is too darn sloooow if you ask me, but it’s happening. ‘Bridge’ and advanced illness management programs are increasingly utilized; the idea of patient-centered medical home is becoming (again) a hot topic; Acute Care for the Elderly (ACE) units are popping up. The fact that there are now so many palliative care physicians is a huge shift from ten years ago.
While I agree that reimbursement and medicare regs for palliative and hospice care are antiquated, we cannot only grumble in frustration waiting for government or insurance companies to get this right. Hospice agencies are growing and struggling. They need referrals to survive AND want/need to provide the best care to grow their services and business. NPs – find out what the hospices/home care agencies perceive to be their limiting factors to reach their goals. Show them that you (we) are the app to meet their needs.
Reimbursement for my service to our hospice however is limited. While Medicare states the NP can serve as attending, state law in Texas and Arkansas do not include NP in the definition of attending physician (that is their language). Medicare only permits reimbursement of NP when they are the attending (a bit of a conundrum for me). I know I help improve the quality of the patient's care with my immediate availability and familiarity with them and their home situation, but I am limited to prescribing Schedule III-V. So, here I think advancing nurse practitioner opportunities in hospice provision of care would be helpful. Just my experience and my thoughts. Thanks for bringing this up!
I do want to mention another thought to prevent re-admission to hospital for those with no "safety net" and serious end stage disease. If we placed, on the discharge planning sheet, information from the Karnovsky or PPS as to where the patient is functionally, and whether they have a terminal disease, and whether they have had a pc consult, or important prognostic conversation with their physician, the "disposition" of the patient becomes a hugely important discharge recommendation. Impossible? We should do it before it's imposed on us....
Regards to all. I wish I could be in Boston with you!
Also, I want to thank all of the wonderful, enlightened MDs on GeriPal that do understand and support us on the forum. Your supportive comments have meant a lot to me. I love being an NP, am one of 8 nurses in my family and have wanted to be an NP for most of my life. On some days however, when I have had to explain the difference between an LVN and an NP and I again have to explain why I can't write the prescription for the opiates even when I am managing all other aspects of the care, or when I have read the statements that the AMA has issued to usurp our role, I wonder why I didn't choose the easier (in some respects), more socially understood role of doctor. When I read the supportive comments here that you have written in support of us, it energizes and sustains me to keep working hard with patients, to keep educating the medical students and to know that one day, others will understand and support the NPs that work in their institutions and in their communities, knowing that we want to work along with you to improve the care that we all give.