By Towana L. Ernst, APN, FNP-BC
As an advance practice nurse working with an in-patient palliative care consultation service in a 600+ bed acute care facility, establishing goals of care for a patient is one of the primary reasons our team is consulted. Our team consists of two physicians, six advance practice nurses (APN), one counselor, one social worker, and pastoral care. On any given day we have between 25-30 patients on our service with average of 98 consults per month and greater than 580 bedside visits per month.
Every day, Monday through Friday, one of our team acts as the quarterback who, when a consult is placed in the Electronic Medical Record (EMR), receives the initial report and assigns the patient in rotation to either the physician or APNs. Information is typically brief and related to the reason for this admission. Our goal is to complete all consults that come in until 4 p.m. as well as round on the patients we are currently seeing. We also rotate weekend coverage with only one provider, who is responsible for seeing the consults as well as rounding on patients that need to be seen. As much as possible we attempt to have continuity of care at the bedside; therefore, we try to limit the number of changes in who is seeing the patient as this typically provides a sense of trust with the patient and goals of care have a more consistent focus.
In order to ascertain the treatment plan, we first identify the healthcare goals of the patient. When we receive the consult, we enter the patient’s chart and begin to gather the pieces of this puzzle. We review demographics, emergency room (ED) notes, history and physical (similar to an admission summary) as well as progress notes, other consultant notes, vital signs, medication records, lab results, imaging studies, notes from social work, physical and occupational therapy. Code status is always reviewed. We are also able to view records from previous admissions and physician office visits if they utilize the same EMR.
Our EMR has a tab marked “Advance Directives” and we review and evaluate the many different documents that might be located in that file such as a Healthcare Power of Attorney (HCPOA), Living Will, Appointment of a Surrogate, or an old or new version of the Do Not Resuscitate (DNR) order. There may also be a document that has been scanned into the chart that identifies a conversation between the patient and a member of a healthcare team that dealt with the subject of advance care planning. The picture that is created throughout this process enables us to look for patterns in the choices patients have made in the past and to better understand the reason for their current admission and choices made up to the present.
Most of us involved in our team might say nothing in life can prepare us for this role, yet everything in our lives has prepared us for this role. While all of the preparatory work is significant, the focal point of the consult is the patient. As we enter the patient’s room we first lay eyes on the person. He or she may or may not be able to communicate with us. Perhaps there is family at the bedside, perhaps not. Has the patient or family or friends ever heard of “palliative care” or when we present the service do facial expressions change from inquisitive and open to overwhelmingly sad? Our patients have many faces. My patient may be a 66-year-old man on his fifth admission this year for advancing end-stage lung disease who is already on the ventilator or will soon need one. In this case, our goal may be to assist this gentleman in establishing his short-term and long-term healthcare plan.
Perhaps the patient is a 72-year-old who came to ED with a persistent cough that has failed antibiotics. A CT scan has revealed multiple lung tumors. She is now facing consults with oncology and surgery and being asked to consider a biopsy as well as further imaging studies that will reveal possible other sites in the body where there may be cancer. Maybe the patient will be a seemingly healthy 42-year-old man who just “dropped” at work and 911 was called, only to find the patient without a pulse or not breathing. Paramedics worked until they regained a heart rhythm; however, time without oxygen to the brain was significant. Patient is on a ventilator and they have his core body temperature down to 92 degrees as part of a protocol to decrease tissue damage and we have been consulted to determine “goals of care.” The patient is sedated and on a ventilator and there is no family at bedside.
These scenarios offer a glimpse of the lives that we touch every day in our practice. We meet with the patient and try to draw out of the conversation the things in life that matter to THAT person. We ask about their life experiences and dare to tread on what will matter in the future. Many times I liken healthcare to a huge bag of goodies filled with tests, treatment, procedures, medications, and machines and encourage them to determine which of these match with their goals for the focus of their care. We review any existing documents where they may have written down choices which also provide guidance for their treatment plan, although each admission may cause the patient to reconsider previous choices and opt for more aggressive treatment or less aggressive treatment.
We also make a special attempt to have a family conference with the primary physician team, the patient, as well as family/friends that are involved in the life of the patient. During this conference, the goal is to establish a treatment plan that is consistent with the goals and choices of the patient or his or her spokesperson. Unfortunately, there are times when the patient has not had discussions with those around them regarding goals for healthcare treatment, and we must look to other individuals for answers. This proves to be an emotional time for the decision maker(s), often times complicated by their own moral and ethical viewpoints.
The mission of palliative care as it relates to establishing a treatment plan based upon the patient’s goals of care is a puzzle. The pieces must be gathered carefully, sometimes daily, although some may be missing. These pieces, together with other components, create a picture that in the end most closely resembles that of the patient. There are no right or wrong answers as each person is an individual who looks at the puzzle today and decides if it looks appropriate for him or her. Life, of course, is not set in stone, and tomorrow the individual may wish for the puzzle to resemble them differently.
Towana Ernst is an advance practice nurse with Palliative Care Consulting Service at OSF Saint Francis Medical Center in Peoria, IL.