Improved quality of life, patient goal-focused care, and decreased health care spending are all benefits of palliative care. Patients who need palliative care often have chronic conditions that can be terminal or non-terminal, such as neurological trauma, cancer, lung disease, Alzheimer’s, Amyotrophic lateral sclerosis, Crohn’s Disease, and many more. Due to the current COVID-19 pandemic, palliative care patients are even more vulnerable because of their underlying medical conditions and potential immune-deficiency. Therefore, they should be guided by healthcare practitioners on how to safely address their health concerns, and access healthcare if needed.

With the advancement of technology and pharmaceuticals, the number of seriously ill people in need of palliative care is growing. Unfortunately, the demand for services is greater than the supply of palliative caregivers. 

Many primary caregivers believe that integrated primary and palliative care is a potential solution. So, what gap between the shortage of palliative care specialists and the demand for palliative care services could NPs fill? What are the skills that comprise primary palliative care and are they already a part of every NP’s practice? Finally, what are additional learning opportunities for NPs to build expertise in primary palliative care?

Components of Palliative Care

In a palliative care facility, the palliative care team consists of doctors and nurse practitioners that work together to help patients meet their life goals. They help relieve symptoms that disrupt the patient’s ability to live their life by adjusting pain medications and diet, help patients understand their diagnosis and treatment options, clarify treatment goals, and coordinate care with other doctors. Most importantly, they work with patients to help them make medical decisions that best align with the patient’s life goals and philosophy.

Palliative care in the United States has primary, secondary, and tertiary levels. Primary palliative care encompasses the basic skills of palliative care and thus can be practiced by nurse practitioners. Secondary palliative care is practiced by clinicians who provide patients with more complex diseases with a consultative approach and specialist knowledge. Finally, tertiary palliative care is practiced at cutting-edge medical research and academic facilities. This is where field advancements are being made.

What Primary Palliative Care Roles Could NPs Take Over?

Nurse practitioners can be found in nearly any medical field or healthcare setting, from major urban hospitals to rural community clinics. For this reason, nurse practitioners are well-positioned to provide thorough symptom assessment and management and initiate and guide conversations around advance care planning.

Symptom Management

NPs can have a huge impact on palliative care patients by helping them with symptom management. Based on a patient’s symptoms, the NP should be able to identify how the patient’s disease/condition is progressing and how this affects the patient’s overall goals.

When it comes to symptom management, an NP is able to examine patients, evaluate their symptoms and conditions, and manage their condition. They are competent to explain different therapies and treatments, as well as the risks and benefits that are present.

But physical pain and discomfort is not the only thing an NP will have to address. Spiritual or emotional distress is equally as likely to be present in palliative patients. To provide the best care possible, NPs should respectfully ask patients about their religious or spiritual beliefs and how to incorporate them into their care plan. This may not be easy; it requires nuanced interpersonal communication and empathy.

Advance Care Planning

Nurse practitioners may also be involved in patient’s advance care planning with their MD and family. When assisting with advance care planning, NPs aid in identifying medical decision-makers for the patient, as well as acknowledging their health care wishes.

An NP working on advanced care planning needs to clearly and openly discuss symptoms, diagnoses, and prognosis for patients and possibly their families. A patient’s illness may be complicated and very serious, so it is important to have these conversations in order to best serve their health care wishes. Ideally, these conversations should initially take place in the outpatient setting so patients and their families can think over these complicated and important decisions.

During advance care planning conversations, be ready to discuss disease progression, potential therapies or interventions, and prognosis. These conversations may not be easy or comfortable, but facilitating open communication about these topics is a learnable skill. There are online resources, such as VitaTalk to build expertise, both with written material and with video demonstrations.  

Other Roles for NPs in Primary Palliative Care

Palliative care is a complex, lengthy process. While NPs can primarily assist in providing symptom management and advance care planning, they could also fill other roles in palliative care in the future.

Transitioning to Hospice Care

When treating patients undergoing palliative care, it is important to discuss hospice care. If NPs believe their patient will succumb to their disease within 6 months, they should have a conversation with the patient about a hospice referral. Although NPs cannot currently sign the certification required to transfer a patient to hospice care, they can inform patients about options and what to expect. If the patient prefers, their Nurse Practitioner can also stay involved in a consultative role after the patient is admitted to hospice. 

Discussing Code Status

In palliative care, discussing code status means talking to the patient about what goals are important to them and what they envision about their quality of life.

Nurse practitioners may have to consult with treating specialists to find out what therapy options are available for their patients. Even if the specialist has already discussed this with the patient, NPs can reinforce important information with the patient later. A consistent message from care providers can greatly contribute to decreasing patient confusion and making them feel more empowered. NPs can offer their patients more information about risks and benefits of treatment, as well as expected outcomes. nurse practitioners should always make sure their patients know they can ask questions and go over what was discussed.

Billing for Advance Care Planning

In the last few years, changes have been made so that NPs can be reimbursed by Medicare Part B and Medicaid for palliative care. According to Kathleen Neuendorf and Mellar Davis, “When face-to-face time includes discussion and documentation on prognosis, treatment choices, and advance directives, this qualifies as advance care planning” and can be billed as such (Wheeler, M.S, 2014). nurse practitioners do not need to fill out relevant legal forms, but they should always use the right codes and adhere to time requirements. Use CPT Code 99497 for the first 30 minutes of conversation CPT 99498for each following 30 minutes of conversation.

Refer When Needed

Nurse practitioners are often not palliative care experts. When faced with difficult, complicated symptoms, delicate family situations, or contentious care decisions, it may be best to consult a palliative care specialist.

Nurse practitioners Fill the Gaps in Primary Palliative Care

Palliative care provides patients with a life-threatening or life-limiting illness the extra support they need to successfully manage their illness and sustain quality of life. New research shows that nurse practitioners are uniquely suited to filling in the existing gaps in palliative care by:

• Assessing medical conditions
• Managing symptoms
• Consulting with specialist
• Offering psychosocial support to patients and families
• Educating patients and families about treatment and prognosis
• Providing ongoing care
• Advocating for patient’s rights and wishes

Clearly, nurse practitioners are a necessary part of primary palliative care and their involvement in the process helps enhanced care for seriously ill patients.

 

Resources:

Colins M. Carmel. “The nurse practitioner role is ideally suited for palliative care practice: A   

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            Jan. 2008, pp. 465-465, doi: 0.1182/asheducation-2008.1.465

Nowels, D., et al. “Perspectives of Primary Care Providers Toward Palliative Care for Their    

Patients.”, The Journal of the American Board of Family Medicine, vol. 29, no.6, Jan. 2016, pp. 748-758, doi: 10.3122/jabfm.2016.06.160054

Parish, M., “Weaving Palliative Care into Primary Care: A Guide for Community Health Centers”,     

            California Healthcare Foundation, https://www.chcf.org/wp-content/uploads/2017/12/PDF-WeavingPalliativeCarePrimaryCare.pdf

Wheeler, Mary S. “Primary Palliative Care for Every Nurse Practitioner”. The Journal for Nurse      

Practitioners, vol. 12, issue 10, Dec. 2016, pp. 647 -653, https://www.npjournal.org/article/S1555-4155(16)30503-7/fulltext

“Palliative Care Considerations for Patients with Cardiovascular Disease Under COVID-19.” American College of Cardiology, 9    Apr. 2020, https://www.acc.org/latest-in- cardiology/articles/2020/04/09/12/42/palliative-care-considerations-for-patients-with-cardiovascular-disease-under-coronavirus-disease-2019-covid-19

“Palliative vs. Hospice Care – Frequently Asked Questions.” Get Palliative Care, https://getpalliativecare.org/whatis/faq/