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Determined to improve pain management and promote optimal patient care at end of life, pain resource nurses at Virtua Health launched an initiative that changed the culture of caring for patients in their final days.

"The evidence shows practice can improve when there is an opportunity and desire for change," says Stephanie Tonetta, APN-C, MSN, AOCNP, a clinical advanced practice nurse and chair of the pain resource nurse committee at Virtua West Jersey Hospital Marlton (N.J.).

A focus group of 23 pain resource nurses representing various disciplines from the Virtua Health system of hospitals met monthly for 16 months to develop an end-of-life education program. They were convinced they could do a better job of helping patients transition from active therapy to comfort measures. These nurses also sought to enhance their colleagues' understanding of the physical, psychosocial, and spiritual needs of patients at end of life. Hospital mortality reviews indicated that several patients had died with do-not-resuscitate orders before palliative care interventions or discussions had been held.

"[Before this initiative] we didn't do the right things to make it as easy a transition as it could be, physically or emotionally, for the families, as well as for the patients who sensed their end was near," says Tracy Carlino, RN, BSN, MA, vice president of patient care services at Virtua West Jersey Marlton.

Evidence-Based Process

The pain resource nurses researched end-of-life care in the literature before brainstorming ideas and taking them to an interdisciplinary team to flesh out the details. The proposals included making policy changes, creating an information sheet explaining the evidence-based changes, developing comfort care order sets, and drafting scripts nurses could use when talking with patients and families.

"Everything we designed is evidence-based," Tonetta says. "The pain resource nurses had support from nursing colleagues, administration, physicians, pharmacists, respiratory therapists, social workers, patient relations, and hospice clinicians, who were essential in making this initative a success."

Relieving Symptoms

Physicians individualize the comfort care order sets once a patient's care goals are transitioned to comfort measures only. The order sets cover everything from resuscitation and intubation status to preferences for the taking of vital signs or allowing dietary freedom. There are check-off boxes for hospice consults and organ donation, as well as fluids, oxygen, and other treatments. Nurses discuss the goals of therapy with patients and family members.

The order set helps nurses quickly initiate treatment for pain, nausea, seizures, or other symptoms that develop as the patient completes the dying process. For example, analgesic titration parameters outlined on the order set include a starting dose, interval increase for milligrams and time, and a maximum dose.

"It's as inclusive as we could do it to touch on the most common symptoms patients experience," Tonetta says.

Gregory Busch, DO, a member of the pain steering committee, took the proposed order set to the medical staff and secured physician support. Many of the physicians like the order set because its use decreases phone requests for additional orders, Tonetta says. But some resisted, objecting to the length of the two-page form. While the physicians are free to work without the order set, its availability helps nurses discuss care options with the physicians.

The pain resource nurses wrote an educational article for the staff to teach them about optimal end-of-life care and how to determine when a patient is appropriate for comfort care. All education materials were distributed via e-mail to interdisciplinary team members throughout the healthcare system and discussed in an educational seminar, "Changing Care and Culture at End of Life." The materials are also available on Virtua's education Web site. Two of the pain resource nurses wrote an article, "End of Life Care: Tools for Success at Virtua Health," which was e-mailed to Virtua physicians.

The order sets and staff education have "helped us think through whether we should be approaching the family, rather than waiting," Carlino says.

Discussing Care Options

The team identified and purchased a booklet, "Gone From My Sight: The Dying Experience," for patients and families. It explains comfort care, signs, and symptoms at end of life. The pain resource nurses also prepared scripts for nurses to follow when discussing end-of-life care and goals with patients and families.

"The scripts were designed to help nurses feel more comfortable with having something to say," says Tonetta. Staff nurses often admit they are apprehensive about starting a conversation with a dying patient, she says.

Some examples of questions nurses might use to begin conversations include, What is your understanding of your condition? What are your wishes/desires/goals regarding your care? There are various treatments available to make you comfortable. Would you like to discuss the options?

The tools developed by the pain resource nurses have elevated end-of-life care for patients at Virtua's four hospitals.

"Nurses can make a difference and impact patient care in a collaborative effort," Tornetta says. "Without nursing's voice, patients would be at a disadvantage. Nurses advocate for them, and they are a link to physicians, families, and peers."

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Debra Anscombe Wood, RN, is a contributing writer for Nursing Spectrum.
To comment, e-mail editorPA@nursingspectrum.com.

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