Early and regular integration of palliative care (PC) improves patient and caregiver outcomes in symptom management, quality of life, psychosocial health, communication, shared decision-making, overall satisfaction—and even survival. Health systems also benefit through reduced emergency department visits, hospitalizations, and intensive care stays; increased completion of advanced directives; and improved quality of end-of-life care. Both the Centers for Medicare and Medicaid Services’ (CMS’s) Oncology Care Model and many oncology organizations, including ONS, support the approach for patients with cancer.
However, patient access to early PC has barriers at both the provider and institutional levels. Many providers believe that introducing PC prevents patients from pursuing active treatment and relinquishes their control of patient care. Institutional culture, limited access to PC specialists, and a lack of time and resources to have meaningful discussions on goals of care and prognosis also limit the approach. Lack of adequate PC training for oncology providers, including oncologists and advanced practice RNs (APRNs), is often a factor.
APRNs’ Role in Palliative Care
APRNs are pivotal contributors to acute, ambulatory, specialty, and primary care PC teams. PC can be implemented in primary, secondary, and tertiary levels of care. At each level, APRNs provide education, clinical care, and consultation (see sidebar).
The American Nurses Association and Hospice and Palliative Nurses Association challenged nurses to lead the culture change and integrate PC into the scope and mainstay of nursing practice. Providing evidence-based training programs such as the End-of-Life Nursing Education Consortium (ELNEC) and including PC in undergraduate and graduate nursing education curricula are essential. The ELNEC program offers a train-the-trainer program that is often free of charge.
APRNs can lead by example and use PC screening tools in practice, which can be integrated into electronic health records to facilitate earlier PC referrals and timely advanced directive discussions. Examples include the Palliative Assessment Screening Tool (PAST) or the Screening for Palliative and End-of-Life Needs in the Emergency Department (SPEED). The “surprise” question can also be used as a quick screening tool: Would you be surprised if this patient died in the next year? If the answer is no, goals-of-care discussions with patients and family members are warranted and PC should be considered.
Advance care planning involves discussion and documentation on prognosis, treatment options, advanced directives, and patients’ wishes and priorities. APRNs may bill for advance care planning conversations and receive CMS reimbursement for goals-of-care discussions. The first 30 minutes of conversation are billed to CPT code 99497, and each subsequent 30 minutes are billed to 99498.
APRNs are often in the position to talk about advance care planning with patients, but unfortunately, only 17% of patients reported having had such a discussion and approximately 90% of patients said they believe they should have the discussion with their physicians. Further research is needed to document the impact that APRNs can have on PC outcomes.