Palliative Care CME & Resources: A Primer for Clinicians
Palliative Care CME
Before we start, we want to make sure you are aware of some palliative care CME so that you can continue your learning. Many states are now requiring palliative care CME as a component of maintaining licensure. We know that’s not the best reason to have to do CME on any subject, but we think you’ll find these particularly interesting. Visit the original post to learn more.
By Kim Spering MSN, CRNP, FNP-BC, ACHPN
What Palliative Care is & What it is Not
What do you think of when you hear the term “palliative care?” Do you think of a patient who is dying? Do you think this refers to hospice? Are you uncomfortable having discussions about patients’ serious illness and disease trajectory?
If you have questions about what palliative medicine entails (or doesn’t) or if you are uncomfortable knowing who may be a good candidate for this service, please read on.
This article will help to shed light on what palliative medicine entails – which is an often-misunderstood concept of health care. I hope to share some personal insights, professional information, and techniques to help you as a clinician understand the palliative medicine role.
I’ll also give you some practical information to help you have these tough conversations with your patients.
History of Palliative Care
Initially, palliative care focused on the care of dying patients. In the 1950’s, Dr. Cicely Saunders became a pioneer of ideas of modern hospice care after observing dying patients. She felt that an interdisciplinary team was required to relieve the “total pain” of a dying person – a concept which continues to be at the heart of palliative care.
Dr. Elisabeth Kubler-Ross, a psychiatrist, penned a book, On Death and Dying, which contributed to major changes in how dying patients were treated.
In the 1970’s, Dr. Balfour Mount described the term “palliative care” to avoid negative bias from the word “hospice.” He discussed providing holistic care for patients and families with chronic or life-limiting illness, helping them with their physical, psychological, social, or spiritual distress.
An Institute of Medicine report in 1997 described limitations & deficiencies in end-of-life care in the United States. At that time, there was a major effort to bring palliative care into “mainstream medicine.”
Clinical practice guidelines were developed and brought to light in 2004, which expanded palliative care to include not only dying patients, but those diagnosed with serious, life-limiting illnesses.
In 2006, the sub-specialty of palliative medicine was recognized and started providing certification for providers. The field has dramatically grown in the past 13 years, with fellowships in palliative medicine, multiple practices focusing on inpatient, clinic, and home-based care, and a definition of “primary” versus “specialty” palliative care.
Definition of Palliative Care
So what is the actual definition of palliative care? It is specialized medical care for people living with a serious illness, at any stage, from diagnosis to later in the disease trajectory.
This care focuses on providing relief from both the physical and psychological symptoms, as well as the stressors occurring because of the illness. Palliative care focuses on the goal of improving the physical, emotional, & spiritual quality of life for the patient and family.
It is appropriate at any age and any stage of the disease trajectory, and can be provided with curative or palliative treatment.
Many providers may be confused about the difference between palliative and hospice care. Palliative care may be offered at any stage of chronic illness – from diagnosis throughout the disease trajectory.
Hospice care, on the other hand, focuses on patients whose disease trajectory would have an estimated life expectancy of 6 months or less. Certainly, there are patients on hospice who live longer than six months, and these patients are re-certified to continue to qualify for hospice care.
Benefits of Palliative Care
Palliative medicine excels at relieving suffering from symptoms and stress.
Palliative care strives to manage symptoms that worsen their quality of life, such as pain, depression, shortness of breath, decreased appetite, sleep problems, anxiety, or other symptoms affecting the patient and family.
Palliative care helps to match treatment options with the patients’ goals of care. We explore a patient’s wishes, hopes, and fears regarding their health conditions. We also discuss treatment options, side effects, and determine if these treatment options are consistent with the patient’s goals of care.
Perhaps a patient wants to have the energy to spend time with his grandchildren, but taking daily radiation treatments for five weeks will make him too fatigued to spend time with them. Exploring a patient’s wishes and goals is crucial to help direct treatment decisions that are RIGHT for the patient.
Palliative care also provides collaboration between different specialties. Often, the cardiologist focuses on the heart, the nephrologist focuses on the kidney, and neither group communicates with each other.
Palliative care clinicians have the ability to bring all of these health issues together, matching the patient’s goals and wishes with treatment options.
Primary and Specialty Palliative Care
It is also important to discuss the differences between “primary” and “specialty” palliative care. Quite simply, primary palliative care can be enacted by anyone.
This may be a family practitioner asking a patient if he/she has an Advance Directive or providing paperwork to help facilitate a patient to document his or her wishes. It may be having a conversation about the patient’s goals of care or wishes for treatment.
Unfortunately, many providers are not comfortable with this conversation, often because they have not received specific education in how to address these issues.
Specialty palliative care refers to a specialized group of clinicians with additional training and expertise in addressing serious illness, disease trajectory, and patient/family support.
The specialty palliative care team includes physicians, nurse practitioners, PAs, nurses, social workers, counselors, and chaplains. The team works to identify physical, psycho-social, and spiritual needs of our patients. They also identify patient/family needs and help manage refractory symptoms, provide patient and family support, and coordinate care among primary and specialty groups.
How to Have a Conversation About Palliative Care
Often, clinicians are hesitant to address these issues because they do not know the type of questions to ask. They may be afraid of “offending” the patient or family. There have been well-validated tools to help clinicians ask the “right” questions in order to elicit the best information possible.
A common tool is the “Serious Illness Conversation Guide.” There are several key tenets of these questions, with examples of patient-tested language listed below:
- Set up the conversation: introduce the purpose, prepare for future decisions, and ask permission.
“I’d like to talk about what is ahead with your illness, and do some thinking in advance about what is important to you, so that I can make sure we provide you with the care you want – Is this okay?
If the patient declines to talk about this, then STOP.
- Assess the patient/family understanding of their disease process(es) and preferences for information.
“What is your understanding now of where you are with your illness?”
“How much information about what is likely to be ahead with your illness would you like from me?”
If patient declines to discuss this, then STOP.
- Sharing Prognosis: frame as “I wish,” “I worry,” or “I hope”
“I want to share with you my understanding of where things are with your illness.
If uncertain prognosis: “It can be difficult to predict what may happen with your illness. I HOPE you will continue to live well for a long time, but I WORRY you could get sick quickly, and I think it is important to prepare for that possibility.”
Time: “I wish that we were not in this situation, but I worry that time may be as short as (insert time frame) – express this in days to weeks, weeks to months, months to a year.
“I hope that this is not the case, but I worry you may not be as strong as you will feel, and things may become more difficult.”
- Explore goals, fears/worries, sources of strength, critical abilities, trade-offs, and family.
“What are your most important goals if your health situation worsens?”
“What are your biggest fears & worries about the future of your health?”
“ What gives you strength as you think about the future with your illness?”
“What abilities are so critical to your life that you can’t imagine living without them?”
“If you become sicker, how much are you willing to go through for the possibility of gaining more time?”
“How much does your family know about your priorities & wishes?”
- Close the conversation: summarize what has been said, make a recommendation, check-in with the patient, and affirm commitment.
“I heard you say that ____ is really important to you. Keeping that in mind, and what we know about your illness, I RECOMMEND that we ____. This will help us make sure that your treatment plans reflect what is important to you.”
“How does this plan seem to you?”
“I will do everything I can to help you through this.”
- Document the conversation and communicate with key clinicians.
Get Ahead of Crises
It is crucial to ask these questions of patients, preferably before a crisis occurs. In the hospital setting, often palliative care clinicians have to broach these difficult topics before deciding on life-saving treatment, such as intubation, CPR/defibrillation, etc.
If patients have not discussed their wishes with their family, there often will be a high level of stress and bewilderment about making decisions for their loved ones.
For that reason, it is generally best if a patient’s wishes and goals of care are discussed ahead of time. Patients generally have a longer relationship with their primary care clinicians and have higher levels of trust in that relationship.
As a nurse practitioner who previously worked in an office setting, I understand that clinicians will often lament, “but I have no time to discuss this with my patients.”
While it is true that the demands of a busy office often limit conversations like this, it is still important to discuss these issues. In my hospital network, we have encouraged providers to have these discussions during an annual Medicare wellness visit or at a post-hospital transition-of-care visit.
Indications for A Palliative Care Consult
In closing, let me share some “triggers” that would cause a clinician to consider a referral to palliative care:
- A patient with frequent hospitalizations for exacerbations of their chronic illness
- A patient who calls the office frequently for guidance in managing their chronic illness. (You know – the ones who take up a lot of your time in-between patients, multiple phone calls, etc.
- A patient with a new diagnosis of a life-limiting illness, such as cancer, COPD, CHF, Parkinson’s disease, dementia, etc.
- Anyone who would benefit from additional psycho-social support in coping with their chronic illness.
Get to know what palliative services are in your area. Some programs only cover inpatient settings, while others operate an outpatient clinic. Still others, like my program, also offer home-based services.
If you are fortunate to have a palliative medicine service in your area, call them up and ask someone to speak with you about what they offer. Palliative care is a collaborative service to assist patients AND providers with management of symptoms, discussions of goals of care, & patient/family support.
Palliative Care CME
As mentioned above, be sure to check out your options for palliative care CME here.
About the Author
Kim Spering MSN, CRNP, FNP-B.C., ACHPN is a board-certified advanced hospice and palliative nurse practitioner who works in a home-based palliative care program.
She has been an NP for over 18 years in multiple settings, including internal medicine, family medicine, & women’s health prior to working in palliative medicine.