Palliative Care for Patients With Life-Limiting or Life-Threatening Illness or Injury

Q How can acute and critical care nurses incorporate palliative care when caring for patients with life-limiting or life-threatening illness or injury?A Bryan Boling, DNP, GANCP, replies:There are 4 key ways that acute and critical care nurses can incorporate palliative care when caring for patients with life-limiting or life-threatening illness or injury: (1) by educating patients and families about palliative care, (2) by advocating for patients to receive palliative care, (3) by communicating effectively with patients and their families, and (4) by providing symptom relief to patients during the dying process.Palliative care is often associated with death and dying and may be confused with hospice. Although the 2 services share similarities, palliative care is not exclusively for the end of life. Many patients, families, and even health care practitioners may view the addition of palliative care as giving up. However, it is better understood as "an approach that improves the quality of life of patients … and their families who are facing problems associated with life-threatening illness."1Nurses can help educate patients and their families about the benefit that palliative care can offer to their treatment. In some cases, that may be by providing symptom relief for patients in the dying process. But palliative care may also be beneficial for patients with chronic health problems, such as heart failure, who are expected to survive their hospitalization. Palliative care can also help with complex decision-making when patients and families are unsure of the best way to proceed.Greater integration of palliative care in the intensive care unit has been associated with improved patient quality of life, increased rates of advanced directive adherence, and decreased use of nonbeneficial treatments at the end of life.2 Nurses are well suited to advocate for the addition of palliative care for their patients. As noted above, palliative care can be helpful with complex decision-making, management of complex symptoms, and end-of-life care.A shortage of palliative care physicians and nurse practitioners is only expected to grow in coming years as demand for palliative care services increases.3 This shortage means that there may be times when it is most appropriate for palliative care services to be provided by the critical care team. However, a formal consult to a palliative care service may be warranted at times. Table 1 shows a list of potential triggers for a formal palliative care consult.Oftentimes, conversations with patients and their families surrounding palliative care are emotional, and it can be difficult for the nurse to understand how best to respond to this emotion. Palliative care physician Dr Jessica McFarlin suggests using NURSE (name, understand, respect, support, and explore) statements to respond to patients and their families.4 Table 2 lists examples of each NURSE statement.Another way that nurses can ensure effective communication is to keep the conversation centered on the patient and their wishes. Nurses may interject their own values, such as by saying things like, "If it were me lying there, I wouldn't want X." Families may do the same, thinking of what they want in the current situation or what they might want for themselves. However, especially when patients are so ill they are unable to speak for themselves, nurses must keep the conversation focused on what the patient would want.The bedside nurse caring for patients at the end of their lives is ultimately responsible for providing care to manage symptoms of dying. These symptoms are varied but may include pain, dyspnea, and even constipation. Table 3 lists some of the common symptoms and measures taken to manage them.Nurses may encounter ethical concerns when administering pain medications to dying patients. The medication may be needed to control pain; however, the nurse may fear that it will accelerate the patient's death by depressing respiration or lowering blood pressure. It is rare that administration of needed pain medication will hasten a patient's death. It is also important to understand the ethical concept of double effect. Pain medication is to relieve suffering, and that outweighs any bad effects that may result.5The acute or critical care nurse is well suited to ensure proper access to palliative care services to patients who are experiencing a life-limiting or life-threatening illness or injury. Although formal palliative care consults and many palliative care treatments require a physician's order, nurses can help by educating patients and their families about palliative care, advocating for the addition of palliative care services by the primary care physician or through a formal palliative care consult, communicating effectively with patients and their families to respond to emotions and keep decisions centered on the patient, and administering medications and other therapies to provide symptom relief during the dying process.