Training Advanced Practice Palliative Care Nurses
Sherman, Deborah Witt, Generations
Beyond just the physical managemnt of disease.
The aging of the population has changed the nature and the needs of people who are dying and has contributed to the recent movement to ensure quality of life and quality of dying at the end of life. Important issues related to the quality of life as death approaches include the following concerns: physical pain and other symptoms, psychological distress (depression and existential anxiety), functioning (physical, emotional, and social), spiritual well-being, social support, planning for preferences in care, and the healthcare provider-patient relationship (Fields and Cassel, 1997). Although quality endof-life care has been available through hospice, only a small proportion of the terminally ill population (15 percent in 1997) has been eligible for hospice benefits or has been referred to hospice by a physician. Since the majority of hospice patients have a cancer diagnosis, with fewer than I percent diagnosed with dementia, new models of care are needed for the elderly, many of whom die of diseases other than cancer, including dementia, and some of whom die because of "multifactorial frailty," or advanced age marked by significant functional impairments that increase over time.
The importance of developing new models of care for the dying was emphasized by the results of sUPPoRT (Knaus et al., 1995), a study that indicated that seriously and terminally ill patients in the United States, many of whom were elderly, experience high levels of pain and receive care that is characterized by inattention to life preferences, aggressive medical treatments, and a lack of communication with their providers. The publication of these results has focused national attention on such issues as the quality of death and dying, pain management, physicianassisted suicide, and the need to move from a curative to a palliative model of care at the end of life.
Palliative care has evolved from hospice care and is defined as "the total active care of patients whose disease is not responsive to curative treatment" The goal of palliative care is to relieve physical, emotional, social, and spiritual pain and suffering and promote the best possible quality of life for patients and their families" (World Health Organization, I99o). Through an interdisciplinary approach, utilizing the expertise of physicians, advanced practice nurses, staff nurses, counselors, and clergy, the goals of care at the end of life are established in accordance with the preferences and wishes of patients and families, with the intent of achieving comfort and, ultimately, a respectful and peaceful death. An interdisciplinary approach also enables healthcare professionals to effectively mobilize each other's skills to meet patients' needs in a variety of healthcare settings, and are appropriate for inpatient palliative units or palliative care consultation teams, for hospice programs in inpatient, community-based or skilled nursing facility programs, and for home-based hospice care.
This article describes the role and responsibilities of advanced practice nurses in palliative care and nursing's initiative in promoting quality care through the educational preparation of these professionals.
THE ROLE AND RESPONSIBILITIES OF ADVANCED PRACTICE NURSES
An advanced practice nurse (APN) is a licensed registered nurse prepared at the graduate level either as a nurse practitioner, clinical specialist, nurse anesthetist, or nurse-midwife and who has specialized knowledge and skills applied within a broad range of patient populations in a variety of practice settings (American Association of Colleges of Nursing, 1999). Advanced practice nursing includes the following: planning and coordinating interdisciplinary interventions for diverse patient population within a variety of healthcare systems, initiating and facilitating organizational change and continuous quality improvement programs in a specific area of practice; facilitating the conduct and utilization of research, developing educational materials and strategies; participating in the formulation of healthcare and social policies; providing consultation in specialty areas; applying ethical and legal principles to healthcare circumstances; and evaluating the effectiveness of care within a specialty area (American Association of Colleges of Nursing, 1999). …