Palliative Care

Screening Presented by Ifey Akanuligo, BSN, RN, Sharon Naithaloor, BSN, RN, Michael

Ngetich, BSN, RN, Kathy Swann, BSN, RN, and Sarah Loughary, BSN, RN

Objectives Define palliative care

Identify difference between Palliative and Hospice care

Discuss the impetus for this project

Screening tool selection

Implementation process

Evaluation

Recommendations / Future Plans

Kansas City Veterans Administration

Medical Center

Hospital is a 128 bed facility

Unit breakdown:

SICU: 8 beds

MICU: 10 beds

PCU: 12 beds

5W Med/Surg: 13 beds

8E Med/Surg/Tele: 24 beds

8W Med/Surg/Oncology/Hospice: 24 beds

10W Inpatient Psych: 9 beds

Additional 28 beds for Substance/Alcohol Abuse Recovery

Palliative vs Hospice Care

Palliative Care Can be offered at any stage of

advanced and or life-threatening illness to those who desire palliation of symptoms whether it be social, physical, emotional, or spiritual

Can be offered along with curative treatment

Admission Criteria

includes a consult to palliative team by the physician

can be provided concurrent with or without a formal Hospice enrollment, and for as long as the patient lives

Hospice Care

Is for the terminally ill (Prognosis of

6 months or less if illness follows its

natural course)

Forgoes curative therapies

Admission criteria

includes certification by two

physician that patient is terminally

ill

Palliative Care is NOT …..

Palliative Care

is

NOT

Only for the imminently

dying

To replace care by the

patient’s PCP

To convince patient to

stop treatment

Hospice

Only when curative

treatment stops

Why Palliative Care ….

What is Palliative Care

Palliative Care – Screening Process

How do we decide, in a timely way, which

patients need specialty-level palliative care services, and then

ensure that they receive those services?

Palliative Care Survey for Staff Prior to

Trial

1. I am comfortable with “breaking the ice” and talking to my patient and their family about palliative care and its benefits. How much do you agree with the above statement?

2. How much do you agree with the statement that our Veterans ought to die with dignity?

3. Do you agree that a patient(s) that you have taken care of at one point could have benefited from palliative care consult/screening?

4. Do you agree that if a palliative care screening tool were available to the nurses at the bedside it could be of benefit to our patients?

5. “Our unit can benefit from a palliative care screening tool”, how much do you agree with this statement?

All questions rated by selecting one: ( )Strongly agree ( )Agree ( )Neutral

( )Disagree ( )Strongly disagree

Literature Review

Center to Advance Palliative Care

The National Comprehensive Cancer Network

Journal of Palliative Medicine

Journal of Hospice & Palliative Nursing

Journal of Oncology Practice

Hospitals/ other Veterans Administration Investigated during the research phase:

Aspire Hospital

Tomah Hospital

Kansas University Medical Center

Columbia Veterans Administration

Denver Veterans Administration

Cincinnati Veteran Administration

Implementation PhaseProcess Steps Person responsible

Who will be responsible for screening the patient, what happens if a

patient screens positive (e.g., daily reassessment for consultation

needs during ICU rounds)?

SICU Nurses

If a palliative care consult is initiated, who will make contact with the

PC team to discuss the consultation question?

SICU Nurses. Project champions and the unit NM will be held responsible to follow

through with the screening results and consult placement

What are the expectations of the ICU from the palliative care

consultant?

• Fill out the palliative care form upon admission and with and any changes

• Once the palliative care needs are addressed put the completed forms in the

PALLIATIVE CARE ENVOLOPE by the assignment sheet.

• Notify PCP regarding the consult and write a comment on the palliative care form

regarding plan of action

• Nurses keep an ongoing conversation about goal of care or plan of care during

morning huddle, SBAR, and on your Kardex

• Notify NM about the positive screen so that they can help facilitate palliative care

consult conversation with staff during morning huddles

Time to complete consultation Upon admission and with any change in status

Follow-up care after initial assessment (e.g. daily follow up and verbal Nurses keep an ongoing conversation about goal of care or plan of care during

morning huddle, SBAR, and on your Kardex

Discussion with (ICU team): Notify NM about the positive screen so that they can help facilitate palliative care

consult conversation with staff during morning huddles

Build in evaluation stopping points to assess and revise screening

criteria and the implementation process

Each trial will include a start and stop date,

a post trial survey & evaluation of the finding at the end of each trial.

If a palliative care consult is not initiated, what steps will occur to

ensure that unmet palliative care needs are addressed, and who will

be the person responsible

Utilize unit specific manager and unit champions to continue to remind nurses to fill out

the 2nd palliative screening tool if there has been a change in patient condition

Expectation during the trial phase

Fill out the palliative care

form upon admission and

with any changes

Once the palliative care

needs are addressed put the completed forms in the PALLIATIVE CARE ENVELOPE

by the assignment sheet.

Notify PCP regarding the

consult and write a comment on the

palliative care form regarding plan of action

Nurses keep an ongoing

conversation about goals of care or plan of

care during morning huddle,

SBAR, and on your Kardex

Notify NM about the positive

screen so that they can help

facilitate palliative care consult

conversation with staff during

morning huddles

Documentation

Palliative Care

Screening

Palliative Care Admission Screen - Discuss Palliative Care Screening based on CAPC Tool and make recommendations to assess goals of care with patient

Enter - Physician notified __________________

For patients who do not meet the Palliative Care Consult at this time, reassess as needed

Palliative Care 1st Trial

Start Date February13 –March 13, 2017

Re-evaluate results of the second trial and

review results with the team on March 13, 2017

Palliative Care Screening Trial #1: Patients with a score of 5 or greater should be considered for a palliative care team consult – please initiate physician notificationSection 1 Basic Disease Process – Two (2)

points per applicable item

____ESRD with dialysis dependence or need

for CRRT

____Advanced COPD

____Progressive or metastatic malignancy

____Severe neurological injury including

CVA, trauma, anoxic encephalopathy

____End stage liver disease with

encephalopathy and / or severe bleeding

____Caner with advanced or metastatic

disease

____Dementia

____CHF/CAD/cardiomyopathy

____2nd readmission for same diagnosis in

last 60 days

____Difficulty weaning off/ prolonged

dependence on ventilator

____Multi-system failure

____Other life limiting or serious progressive

illness

Section 2

Modifiers and Situations: 1 point for each

____ Complex situation or need for ongoing care

coordination

____ Uncontrolled or unsatisfactory symptom

control of pain, nausea, delirium, etc, >24 hours

____Transplant or organ donation being considered

____PEG, tracheostomy, AICD or other long term

device placement being discussed (or already in

place)

____Unrealistic or divergent family opinions about

care (including not following advanced directives)

____No advanced directives, spokesperson or loss

of primary care giver ability to continue care

____Unmet psychosocial or spiritual needs

____Frequent Emergency Department visits in the

last 60 days with the same diagnosis

____Prolonged stay in the ICU without evidence of

progress or poor prognosis

____Is not a candidate for curative treatment

____Has a life limiting illness and has opted to not

have treatment

Section 3

____Would you be surprised if patient died in next 12

months? (Yes=0 points; No=2 points)

Functional Status of Patient - Eastern Cooperative

Oncology Group (ECOG) Performance Status Scale

____1 Fully active able to carry on all pre-disease

activities without restriction.

____2 Restricted in physically strenuous activity but

ambulatory and able to carry out work of a light or

sedentary nature (e.g. light housework, office work).

____3 Ambulatory and capable of all self-care but

unable to carry out any work activities. Up and about

more than 50% of waking hours.

____4 Capable of only limited self-care; confined to bed

or chair more than 50% of waking hours.

____5 Completely disabled. Cannot carry on any self-

care. Totally confined to bed or chair.

Total Points Section ______ Total points Section ______ Total points Section ______

1st Post Palliative Care Assessment Survey

Results – Nurses ResponseIs the screening process working to identify the patients with the greatest needs 56% YES

Do you believe our patient would benefit from palliative screening tool? 100% YES

If you used the screening tool but did not contact the physician for a consult can you indicate

the reason why?18 % N/A

Do you feel comfortable screening a patient for palliative care? 81% YES

Is the tool user friendly? 56% YES

Is the tool helping you initiate palliative care conversation with the physician? 62% YES

Where would you suggest the Palliative Care Screening tool be implemented? o Admission Database 68%

o Another Template 18%

Would you be more apt to using this tool? If this screening tool initiated an automatic electronic

alert being sent to the PCP and did not require you to talk with the physician?81% YES

Did you feel like the physicians were receptive to considering a palliative care consult? 25% Sometimes

12% YES

What would you like revised about the screening tool? (Recommendations / Suggestions/

Comments / Questions)None

1st Post Palliative Care Assessment Survey

Results – Patient ScreenedTotal number of patient screened during the 30 day trial period 25

Total number of patient who met Palliative Care Consult criteria based on the Screening Tool 8

Total number of patient who benefited from the use of the screening tool 0

Total number of patients with positive screening tool that were left unaddressed by physician

Reason:

• MD unable to make a decision

• MD did not feel patient needed a palliative consult at the time

2

Number of patient unaccounted for?

Reason:

• Unable to track because of no identification label on the screening tool

• Unable to find any documentation from nursing stand point to show screening tool was

addressed with the primary team

• One case where the patient had an existing consult from January but no new consult during

the trial phase.

1

4

1

Palliative Care 2nd trial

Start Date July 12- August 12, 2017

Re-evaluate results of the second trial and review results with the team on

August 21, 2017

Palliative Care Screening ToolCriteria for a Palliative Care Assessment at the Time of Admission

Primary Criteria A _ The ‘‘surprise question’’: You would not be surprised if the patient died within 12 months or before adulthood _ Frequent admissions (e.g., more than one admission for same condition within several months) _ Admission prompted by difficult-to-control physical or psychological symptoms (e.g., moderate-to-severe symptom intensity for more than 24–48 hours) _ Complex care requirements (e.g., functional dependency; complex home support for ventilator/antibiotics/feedings) _ Decline in function, feeding intolerance, or unintended decline in weight (e.g., failure to thrive)

Secondary Criteria B _ Admission from long-term care facility or medical foster home _ Elderly patient, cognitively impaired, with acute hip fracture _ Metastatic or locally advanced incurable cancer _ Chronic home oxygen use _ Out-of-hospital cardiac arrest _ Current or past hospice program enrollee _ Limited social support (e.g., family stress, chronic mental illness) _ No history of completing an advance care planning discussion/document

Patient would be considered to have a positive screen if he or she has a positive response to 3 or more question

Patient Sticker: __________________________RN initial: _________________Physician notified: __________________Time:___________ Date: ________________

Comments: ______________________________________________________________________________________________

Palliative Care Screening Tool

Criteria for Palliative Care Assessment during Each Hospital Day as needs change

Primary Criteria A _ The ‘‘surprise question’’: You would not be surprised if the patient died within 12 months or did not live to adulthood _ Difficult-to-control physical or psychological symptoms (e.g., more than one admission for same condition within several months) _ Intensive Care Unit length of stay _7 days _ Lack of Goals of Care clarity and documentation _ Disagreements or uncertainty among the patient, staff, and/or family concerning (e.g.; major medical treatment decisions, resuscitation preferences, use of nonoral feeding or hydration)

Secondary Criteria B _ Awaiting, or deemed ineligible for, solid-organ transplantation _ Patient/family/surrogate emotional, spiritual, or relational distress _ Patient/family/surrogate request for palliative care/hospice services _ Patient is considered a potential candidate, or medical team is considering seeking consultation, for: (e.g.; feeding tube placement, tracheostomy, initiation of renal replacement therapy, ethics concerns, LVAD or AICD placement, LTAC hospital or medical foster home disposition, bone marrow transplantation (high-risk patients)

Patient Sticker: __________________________RN Initial: _________________Physician notified: __________________Time:___________ Date: ________________

Comments __________________________________________________________________________________________________

2nd Post Palliative Care Assessment Survey ResultsTotal number of patients screened during the trial phase between July 12th

2017 – August 12th 2017

43

Total number of patient with positive screen during the trial phase 5

Total number of patient with a positive screen who received evaluation by a

palliative care member

5

Is the screening process working to identify the patient with the greatest 16/18 said yes. Other two

haven’t used the tool enough

Do you believe our patient benefited from the palliative screening tool 16/18 one not sure, the other two

felt like patient would benefit if

physician would follow through

Do you feel comfortable screening for palliative care 16/18 yes, one mostly, and one

not comfortable

Is the tool friendly 100 % yes. A request for

electronic version

Is tool helping you initiate palliative care consult with the physician –

sometimes teams aren’t always receptive

100 % yes !

Do you feel you need more resources to enable you to complete your

screening tool effectively

1 not sure

What would you like revised about the screening tool? (Recommendation,

suggestions, comments, questions)

None.

Current Progress

Presented to Clinical Practice Committee in November

Presented to Executive Council of Nursing Staff in December

Approved to roll out practice to SICU, MICU, PCU, and 8W

Started February 1st

Sustainability / Future Plans

Future Plans Help generate more champions in

other units, educate staff nurses and

physicians in other areas, generate

increased awareness through

education, be available when

needed to answer questions

Recommendations Help spread the practice to other

areas to improve quality of life and

reduce our SMR scores

Moral Distress Defined

“When one knows the right thing to do, but institutional constraints make it

nearly impossible to pursue the right course of action” –Jameton

Repeated and unaddressed situations lead to moral residue

3 categories of root causes

Clinical situations

Internal factors

External factors

Contributing Factors to Moral Distress

Internal Constraints

External Constraints

Clinical Situations

Lack of Self-Confidence

Fear

Maladaptive Coping

Religious/Spiritual Conflicts

Lack of Collegiality

Hierarchical Structure

Poor Communication

Inadequate Staffing

Restrictive Policies

Futile Treatment

Inappropriate Care

Inadequate Pain Relief

Incompetent Coworkers

Hastening Dying

False Hope

Source: "Moral Distress in ICU Nurses." Intensive Care Medicine, vol. 42, no. 10, Oct. 2016, pp. 1615-1617. EBSCOhost, doi:10.1007/s00134-016-4441-1.

Problems Stemming from Moral Distress

Short-Term

Consequences

Feelings of Powerlessness

Withdrawal from morally

charged situations

Impaired patient care

Long-Term

Consequences

Emotional Withdrawal

Emotional Exhaustion

Depersonalization

Burnout syndrome

Moral Distress Scale-Revised

Survey used to identify moral distress

Designed for critical care nurses

32 items that deal with clinical situations

Moral Distress Scale-Revised (MDS-R)

21 items

6 parallel versions for nurses, physicians, and other healthcare professionals

0-4 Likert scale for both frequency and level of disturbance

Table 1. Moral Distress Scale-Revised Scores

Professional group (n) Mean score, range

Profession

Nurses (38) 91.66, 16-197

Setting

Medical Intensive Care Unit (20) 86.65, 16-197

Progressive Care Unit (8) 114, 46-174

Medical/Surgical/Oncology/Hospice Unit (10) 83.3, 25-160

2.76

5.02

9.5

8

2.76

7.42

4.11

0.97

5.05

1.79

3.95

8.21

1.58 1.32

0.29

3.21

4.42

6.55

1.71

66.71

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Me

an

Sc

ore

s

MDS-R Survey Item Number

Average Score of Moral Distress (frequency x intensity) per Survey

Item, Combined Scores

Table 2. Root Causes of Moral Distress

MDS-R

Mean (SD)

Rank

Following family’s wishes for life support when not in best

interest of patient

9.5 (5.42) 1

Initiating life-saving actions to only prolong death 8 (5.26) 2

Providing care that doesn’t relieve patient’s suffering

because physician fears dose will result in death

8.21 (6.09) 3

Carrying out orders that are considered unnecessary 7.42 (5.08) 4

Working with unsafe staffing levels 6.71 (5.08) 5

Witnessing diminished care due to poor communication 6.55 (2.94) 6

Working with incompetent providers 5.05 (5.03) 7

Witnessing providers giving false hope 5.02 (4.62) 8

Range for item scores 0-16. MDS-R = Moral Distress Scale-Revised

Table 3. Intention to Leave a Position

n (%)

Never considered leaving 19 (50.0)

Considered but did not leave 15 (39.5)

Left job 1 (2.6)

Not considering leaving now 22 (57.9)

Considering leaving now 11 (28.9)

Possible Interventions

Ethics Education

Ethics Committees

Multidisciplinary Ethics Rounds

Formal Debriefings

End-of-life/futile care policies

Consider the Future of Palliative Care

American hospitals are filling rapidly with seriously ill and

frail adults. By 2030, the number of people in the United

States over the age of 85 is expected to double to 8.5

million

Most people facing serious illness will end up in the

hospital at some point in their illness

Hallmarks of A Vital New Trend: Time,

Communication, Expertise, Quality, Coordination

and SupportPalliative care responds to the episodic and

long-term nature of serious and chronic illnesses. These are the pillars of palliative care.

Improve quality—and lower costs—of hospital care.

Handle time-intensive patient/family/physician

meetings.

Improve quality of life for patients and families struggling with serious

illnesses they might live with for years, including heart and lung disease, diabetes, cancer and

Alzheimer’s disease.

Coordinate care for patients and families dealing with multiple doctors and a fragmented medical system.

Support patients and families struggling with complex decisions.

Provide specialty-level assistance to the attending physician for difficult-to-treat pain and other symptoms,

including nausea, shortness of breath, fatigue, constipation and

depression.

Palliative Care Cost

On average, palliative care consultation is associated

with reductions of $1,700 per admission for live discharges and reductions of $4,900 per admission for patients who

died in the hospital.

This means savings of more than $1.3 million for a 300-

bed community hospital and more than $2.5 million for the average academic medical

center.

Available Resources

Palliative Care Team: (Dr. Kallenbaugh; Kelly Artis, Social Worker; Cheryl

Buntz, SICU Nurse Manager; Palliative Care Team Champions)

Palliative Care Hand-out and Book will remain available for in-patient and

nurses in the SICU

References

Lapp, E., I., & L. (2015, December). Examination of a Palliative Care Screening Tool in Intensive Care Unit Patients. Retrieved November 9, 2017, from http://journals.lww.com/jhpn/Abstract/2015/12000/Examination_of_a_Palliative_Care_Screening_Tool_in.15.aspx

Hamric, Ann Baile, et al. "Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals." AJOB Primary Research, vol. 3, no. 2, Apr-Jun2012, pp. 1-9. EBSCOhost, doi:10.1080/21507716.2011.652337.

Mealer, Meredith and Marc Moss. "Moral Distress in ICU Nurses." Intensive Care Medicine, vol. 42, no. 10, Oct. 2016, pp. 1615-1617. EBSCOhost, doi:10.1007/s00134-016-4441-1.

Nelson Je et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project. Crit Care Med. 2010 Sep;38(9):1765–72. doi: 10.1097/CCM.0b013e3181e8ad23. Available at: http://www.capc.org/ipal/ipal-icu/monographs-and-publications.

Nelson Je et al. Choosing and using screening criteria for palliative care consultation in the ICU. Crit Care Med. 2013 (in press).

Nelson Je et al. Organizing an ICU Palliative Care Initiative: A Technical Assistance Monograph from The IPAL-ICU Project. Center to Advance Palliative Care; 2010; http://www.capc.org/ipal/ipal-icu/monographs-and-publications.

Palliative Care | Serious Illness | Get Palliative Care https://getpalliativecare.org

Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011 Jan;14(1):17–23. doi: 10.1089/jpm.2010.0347.

Whitehead, P.B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., and Fisher, J. M. Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey. Journal of Nursing Scholarship, 2015. p. 117-125.

Palliative Care

Questions, concerns,

or comments

?