A nurse practitioner is valuable in hospice and palliative care

by Patrice Villars

Recently, 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.

Patrice Villars is a nurse practitioner at the University of California, San Francisco who blogs at GeriPal.

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  • Pat Jonas, MD

    Well written piece to open some physician eyes about the limitations of hospice nurses. Why would a physician who felt competent to manage pain and suffering and various diseases in a patient suddenly defer the care of those issues to a non-physician? As a family physician, I’m well trained in end of life care and the use of palliative modalities, including physical, emotional and spiritual support. Family issues are also in my scope of practice. Health System issues, including teamwork and collaboration are a key part of family medicine, so I am comfortable relating to the hospice nurse and providing comfort to her that she won’t have to feel pressured to “practice medicine” for my home hospice patient. I am comfortable with my patient’s health circumstances and the use of all medicines that may be used. I also care for everyone in the household of my dying patient, which provides some extra insights about the family issues. I have the hospice nurse call me every time she’s in my patient’s home so I can learn from her about my patient’s situation and the family situation. Their nursing opinion and skills are uniquely valuable and my family medicine skills are, too, as we team together to relate as humans and health professionals to the patient, their family and each other. Some of my suburban and small town experiences may differ from people in other settings.
    I loved the thought provoking article by Patrice Villars. Thanks

    • mike

      Doctor, thank you for your insight. You are indeed the exception rather than the rule. I am amazed that you have time to keep that close of contact with patients, but I’m glad you do.

  • Primary Care Internist

    I have found hospice services, in the nursing home setting, redundant and sometimes confusing.

    However in the home setting a good hospice nurse is sometimes invaluable (depending on the agency & nurse, of course). If a good agency provides good longitudinal care in the last few weeks or months of life to a patient with a large involved family, that nurse can really inspire confidence, and even add value as these patients might otherwise occasionally be cared for in an expensive and unpleasant hospital environment.

    • just a patient

      My mother-in-law was in a nursing home for 7 years because we couldn’t take care of her in the home, thanks to Alzheimer’s. At the end of her life, we lobbied hard for hospice care (and got it), because there were pain management options and other comfort measures available from hospice that weren’t available with standard nuring home protocols. Her care was essentially taken over by the hospice staff (RN’s & CNA’s), while she continued to reside in the nursing home bed. It also assured that she went to a private room, so that she was not disturbing another resident.

  • Marian Paull, GNP

    I am GNP in NJ working with a “visiting physician” group who specialize in home care. I have many opportunities to engage with Hospice on a wide variety of end of life diagnoses and your concerns about the “one size fits all” prescriptions have also bothered me. As far as the treatment of end stage CHF and COPD are concerned it seems that it depends on the mission +/or quality of the hospice organization or sometimes specifically the case manager RN, as to how they proceed with a person in distress. In NJ, Hospice organizations have recently started communicating in writing regularly with the referring MD about the progress and plan of care for the patient, which gives you the opportunity to at least step in an counsel changes. I love hospice for all the good they do and so do my patients but it is definitely a collaborative effort with a more broad therapeutic range than just MS, lorazepam and haldol.

  • pat

    As a PA, the problems I see with this are 1) it leaves us out entirely and 2) the disparate training provided to many NPs. The writer of this piece is from University of California at San Francisco which provides a great NP program, no doubt. Their product is superb and I chose one in the past as a personal clinician as well as an NP from UC Davis. California NPs currently must have a supervising physician in order to prescribe.

    In the state where I now work, however, NPs are not well trained and do their clinical “rotations” in one to two day shadowing experiences over the period of six months to a year solely in small practice, non-academic settings. Their preceptors and didactic instructors are all NPs and not MDs.

    US NP training is not accredited by one central agency nor is licensing determined by one consistent examination. The two major certification organizations for NPs do not have physician representation. Only recently has an exam been developed in conjunction with medical education representatives; this exam is only for doctoral NPs and currently has had only a 50% pass rate. Passage is not required for licensure.

    Depending on specialty, the NP has hundreds of paths to licensure and practice and is not required to be re-examined at any specified interval. Their training can range from 90 days to 3 years, but the current national model is based on part time clinical training and, frequently, on-line or distance based didactic training, for both masters and doctoral (DNP) programs. NPs may or may not need or use collaborating or supervising physicians, depending on state of practice,

    All US PAs must initially be certified by the NCCPA prior to licensure. The entry level examination is actually constructed through a contract with the National Board of Medical Examiners, and the NCCPA Board of Directors contains many physician representatives from the AMA, ACP, ACS, etc. The graduate PA, regardless of degree level (almost 90% are currently masters programs, , is held to the same competencies as all other PAs and judged by the same examination. PAs in most states have an ongoing maintenance of certification policy, like physicians, that depends on proctored re-examination at specified intervals. All PAs must work in teams containing a physician.

    When NP training and licensure is standardized, accredited by one body and evaluated by one exam, maintenance of certification is introduced, and physician collaboration assured, it might be okay to consider this model.

    • brooke franklin

      Really? You read this entire article and all you got out of it was a reason to bash NP’s? Why do most PA’s who comment on articles and blogs always find it necessary to talk about NP’s and how inadequate or ignorant they are? Are you bored or something?

  • http://geripal.org Patrice Villars

    Appreciate all your thoughtful comments. My hope in writing this piece is to ask us, as health care providers, how we might identify barriers to best practice end-of-life care given our current medical and regulatory model (i.e. government defined hospice and limited availability to many primary providers) while understanding our similar and distinct disciplines. That said, Pat MD makes a good point, many physicians know their patients well, know end-of-life care well, and follow their patients closely in or out of hospice care. But not all can or do. I think the transition and the communication need to be improved in many settings. While I argue that NPs may be the optimal discipline to bridge this gap, Pat PA, also reminds us that all mid level providers, PAs and NPs, offer similar benefit. (A side note clarification to Pat PA’s comment: NPs are their own profession with their own licenses and state practice acts and are, therefore, not tied to MD representation. NP graduate school accreditors are very specific as to the type and quality of the clinical training sites and preceptors and focus highly on quality. [For example, just CCNE visited UCSF a few weeks ago.]) While I argue that NPs are advantageous in a hospice setting because they are nurses, both PAs and NPs have advanced training in primary care and management of chronic illness. And both might need further expertise in palliative and geriatric care in order to optimally manage end of life illnesses. I think our similarities as mid level providers well outweighs our differences.

  • http://www.hpcnd.org Sheila Grant, RN, BSN, CHPN

    I work as a hospice nurse-educator, and I have ten years of experience in hospice nursing. While I agree with Ms. Villars’ point that there is a valuable place for NP’s in Hospice, I must take issue with a few of her supporting points.

    Ms. Villars writes that hospice RN’s use simple algorithms to treat symptoms: “Shortness of breath equals morphine; anxiety equals lorazepam; confusion/agitation equals haldol.” On the contrary, a quick look at the HPNA Core Competencies for Hospice and Palliative Nurses will show that hospice nurses are educated to discern the complex causes of pain/dyspnea/anxiety/confusion, report their findings to the attending physician, and request appropriate, individualized orders. HPNA also publishes a Competencies for Advance Practice Hospice and Palliative Nurses, a good tool to differentiate the practice of Hospice RN’s and APN’s.

    On the topic of managing end-stage congestive heart failure, I was particularly struck by the comments of Ms. Villars’ friend who didn’t want to put her mother on hospice, because “they’ll just give her morphine and Ativan. I want her heart failure managed.” Management of end-stage CHF is one of our greatest successes in hospice. A 2007 study in the Journal of Pain and Symptom Management compared matched groups of patients, one of which chose hospice care, and the other standard care. Results showed hospice patients with CHF lived and average of 81 days longer on hospice.

    We do an especially good job of monitoring and managing fluid status by visiting frequently, checking for signs of fluid overload, and providing channels of communication between patient, family, CNA, RN, and physician. I’m quite a firm believer that good hospice care prevents fluid overload, symptoms, and hospitalizations for CHF. In fact, I would recommend hospice as the best way to manage end-stage CHF, and I have done so for my own family members.

    Ms. Villars is also critical of the “one size fits all” quality of our home PRN kits. It’s important to note that these kits are meant as a tool to get us through the night, when symptoms can be severe and distressing, and attending physicians and pharmacies are often not available. It gives us something to work with for the most common symptoms. Many nursing homes have similar kits or boxes of PRN medicines for these situations. When the sun comes up, we do a thorough nursing assessment, communicate with the patient’s physician, and make changes to our individualized plan of care.

    Having said all that, I believe NP-Physician Co-Director teams would be wonderful. While the hospice I work for has a full-time medical director who makes home visits, many do not. I hope we will soon see regulatory and reimbursement changes to expand the role of NP’s in hospice.

    Sheila Grant, RN, BSN, CHPN
    Clinical Educator, Delaware Operations
    Compassionate Care Hospice
    Wilmington, Delaware
    (302) 530-0712

    see my LinkedIn Profile at: http://www.linkedin.com/in/sheilagrant

    • Pat Jonas, MD

      Great comments by Sheila Grant, RN, BSN, CHPN to further clarify roles and skills of hospice nurses. I am stunned by her comment about how the hospice nurse has to “make it through the night” seemingly alone and maybe even feeling abandoned by attending physicians who “often” are not available. How has hospice nursing formally pursued action against this unprofessional physician behavior? How have hospice medical directors, who apparently are among those “often” unavailable” been apprised of their unprofessional behavior? How can nurses stay in hospice employment if they are to be exposed to unprofessional abandonment at night by physicians when “symptoms can be severe and distressing”?
      Are Miss Grants comments representative of the rest of the hospice world where physicians are “often” unavailable? If so, who will fix this disastrous situation and who will apprise the public about this horrendous failure of the medical profession and the inability of the nursing profession to prevent their peers from feeling abandoned?
      Please see my previous post about how I value the unique skills and abilities of hospice nurses in the Dayton, Ohio area. I’m sorry to hear about how it is at night in Delaware, apparently because of physicians.

      • http://www.hpcnd.org Sheila Grant, RN, BSN, CHPN

        I’m sorry I wasn’t clear about physician’s being “unavailable”. I meant the patient’s own physician who knows them may be unavailable. At night, we are likely to reach the primary doctor’s partner or an on-call physician who is unfamiliar with the patient. We can always reach our medical director, but an order for medication is of no use when the pharmacy is closed.

        My meaning in this paragraph was not to imply that the hospice nurse is “alone” or “abandoned”, but to explain the need for the limited emergency kit of medications. We are well-supported in the off-hours, but the medicines in the kit are meant to supply us in an emergency, not to meet all the patient’s needs.

        Sorry for the misunderstanding.
        Sheila Grant, RN, BSN, CHPN

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