Incapacitated Surrogates: A New and Increasing Dilemma in Hospital Care.

A power of attorney for healthcare (POAHC) form gives designated individuals legal status to make healthcare decisions when patients are unable to convey their decisions to medical staff. Completion of a POAHC form is crucial in the provision of comprehensive healthcare, since it helps to ensure that patients' interests, values, and preferences are represented in decisions about their medical treatment. Because increasing numbers of people suffer from debilitating illness and cognitive deficits, healthcare systems may be called upon to navigate the complexities of patients' care without clear directives from the patients themselves. Hence, the healthcare industry encourages all individuals to complete a POAHC form to ensure that persons who have the patients' trust are able to act as their surrogate decision makers. However, sometimes POAHC agents, even when they are patients' trusted agents, lack the capacity to make fully informed decisions that are in the patients' best interests. We describe designated surrogate decision makers who have impaired or diminished judgment capacity as incapacitated surrogates. Decision making that is obviously flawed or questionable is a significant impediment to providing timely and appropriate care to patients. Moreover, failure to redress these issues in a timely and efficient manner can result in significant costs to an institution and a diminished quality of patient care. The authors offer a legal, ethical, and interdisciplinary framework to help navigate cases of incapacitated surrogates.

Use of the Palliative Performance Scale version 2 in obtaining palliative care consults.

AIMS AND OBJECTIVES: To examine whether an educational intervention and implementation of a validated prognostication tool can improve inpatient acute care nurses' knowledge of palliative care and their comfort in determining the need for palliative care and requesting a palliative care consult from the attending physician. BACKGROUND: Patients with chronic illness report low levels of quality of life. Relief from suffering may be found in services provided by palliative care; however, their services are often underused, in part, due to difficulties in prognostication. The Palliative Performance Scale version 2 is a prognostication tool that can help overcome this barrier. DESIGN: A pretest/post-test design with nursing education intervention was used on an acute care medical unit within a Midwest tertiary hospital. METHOD: Survey questions for both pre- and postintervention assessed nurses' knowledge related to palliative care and examined nurses' comfort in identifying patients appropriate for palliative care and requesting consults. Following the presurvey, education on palliative care and the use of the Palliative Performance Scale version 2 was provided during a regularly scheduled staff meeting. Posteducation mentoring occurred for one month prior to the postsurvey. RESULTS: Pre- and post-test comparisons showed an overall increase in both comfort and knowledge related to palliative care. There was also a significant improvement in the nurses' comfort in identifying patients appropriate for palliative care. CONCLUSIONS: Findings suggest that nursing education on palliative care and Palliative Performance Scale version 2 can improve their knowledge level and comfort in requesting palliative care consults. RELEVANCE TO CLINICAL PRACTICE: Nurses are in the best position to advocate for the patient and the management of their chronic illness. Educating nurses on the philosophy of palliative care and improving their comfort level in assessing the need for palliative care will overcome barriers to consultation.

Designing a Mentorship Program for APRNs in Specialty Palliative Care Practice.

ABSTRACT: As advanced practice registered nurses (APRNs) enter practice, support is crucial for success. Formal mentorship has been shown to improve employee turnover, job satisfaction, and clinical competence. In the wake of the COVID-19 pandemic, an APRN team specializing in palliative care experienced an unprecedented rate of staff turnover. As a result, the team decided to create a formal mentorship program to support newly hired colleagues and assist their transition to practice. A subcommittee of APRNs within the palliative care practice met to establish a mentorship practice framework, expectations for the program, and a methodology for matching mentors and mentees. The mentorship program was implemented with two cohorts comprising a total of five mentors and six mentees. It was evaluated by participants using surveys asking open-ended, qualitative questions. Both mentors and mentees reported finding the program valuable. Mentees felt the program helped their transition to practice, created a forum for peer support, and improved their clinical competence. Mentors said the program furthered their own professional development, advanced their clinical growth, and fostered a connection to colleagues. Employee engagement and alignment improved, and staff turnover decreased. Further work is needed to improve on the program framework and analyze the outcomes of mentorship.

Clinical Nurse Specialist Collaboration With a Community-Based Palliative Care Program: An Evidence-Based Practice Project.

PURPOSE/OBJECTIVES: The purpose of the project was to evaluate the impact of a clinical nurse specialist (CNS) collaborating with an established Midwestern community-based palliative care program on the following quality outcomes: care coordination, 30-day readmissions, and emergency department (ED) utilization. DESCRIPTION OF PROJECT: Palliative care services are evolving from the inpatient setting to community-based models to meet the needs of patients in their homes. As community-based programs develop, healthcare systems are examining the various models of care. The evidence-based practice project evaluated a collaborative practice model between a CNS and a community-based palliative care team. Quantitative analysis included 30-day readmissions and ED utilization in a preimplementation and postimplementation design. Qualitative data were obtained from a focus group of the community-based palliative care team to discuss the role of the CNS on the team. OUTCOMES: The addition of a CNS did not significantly impact 30-day readmissions or ED visits. An unexpected outcome was that the CNS intervention was associated with an increase in social work visits. Results of the focus groups suggested that the CNS improved care coordination, nursing support, education, and medical management. CONCLUSION: Both quantitative and qualitative analyses suggest that the CNS enhanced coordination of care and quality outcomes. Examining the CNS contribution over a longer period will further clarify the CNS's impact to the team.

Creation of a palliative care advanced practice registered nurse peer-review process.

The mark of a true profession is the ability to self-regulate. As such, advanced practice registered nurses (APRNs) are challenged by their professional organisations to participate in self-evaluation and peer review. Peer review is a method for evaluating the care provided by the APRN to both ensure quality nursing care and promote professional growth. Despite guidelines to participate in a formal peer-review process, there is little information within the nursing profession on how to accomplish peer review. A comprehensive literature review failed to provide a framework for peer review that is practice focused, fosters a learning environment and encompasses the thought process and clinical decision-making of the palliative care advanced practice nurse. A group of palliative care APRNs set out to create a process that encompassed the breadth of clinical decision-making in palliative care advanced nursing practice. Using the eight domains of palliative care, a narrative case review structure was created. The resulting process both assisted the APRNs in professional growth and provided timely feedback for the annual performance evaluation.