International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

New Frontiers in Outpatient Palliative Care for Patients With Cancer.

BACKGROUND: Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. METHODS: This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. RESULTS: Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. CONCLUSIONS: Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.

Cultural Advocacy for Indigenous Individuals With Serious Illness.

Indigenous American (I.A.) individuals with serious illness and their families have unmet needs. Often, this group is viewed as a minority within a minority. Numerous health challenges exist within the I.A. populations resulting in dire health care situations. Historical trauma and mistrust of the healthcare system impacts access to quality palliative care by this marginalized population. Given the range of social, spiritual, and cultural issues, the interprofessional team needs increased knowledge specific to the I.A. population to ensure holistic, culturally sensitive care. Utilizing a case study, this article reviews of the needs of I.A. individuals with serious illness and essential skills. The aim is empower palliative care clinicians the knowledge to provide culturally sensitive and congruent care to I.A. individuals with serious illness and their community.

A survey of current specialty palliative care education in the United States.

Palliative care (PC) is a health care specialty that is focused on the holistic care of individuals with serious illness. It requires interprofessional collaboration and expertise to meet the physical, psychosocial, social, cultural, and spiritual needs of patients experiencing serious illness and their families. The interprofessional team (IPT) is most often composed of Advanced Practice Providers (APPs) [including Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Associates/Assistants (PAs)], Chaplains, Registered Nurses (RNs), Doctors of Medicine and Doctors of Osteopathic Medicine (MDs/DOs), Registered Pharmacists (RPhs), Social Workers (SWs) and other professions depending on site of care, the age of the patient, and the illness. The United States has specialty palliative care (SPC) IPT members who have completed advanced education and training and obtained specialty certification. However, there is currently no interprofessional consensus education and training resulting in interprofessional variability of definitions of education and requirements for academic preparation into the specialty. This article offers the results of an online review and survey of the current availability of SPC education in the United States which includes certificate programs, residencies, fellowships, and immersion programs available to each profession. The purpose of this review is to unify the available information regarding SPC programs, providing a succinct, yet thorough, overview of the SPC educational landscape. It emphasizes the length of time, cost, and delivery method for IPT members in choosing programs.

Early palliative care for patients with metastatic non-small-cell lung cancer.

BACKGROUND: Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. METHODS: We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. RESULTS: Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02). CONCLUSIONS: Among patients with metastatic non-small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

Resourcefulness and stress among hospice and palliative nurses: the role of positive thinking.

Background: Among healthcare professionals, hospice and palliative nurses have a high risk of experiencing work stress. However, little attention has been paid to protective factors that could mitigate the impact of daily stressors on hospice and palliative nurses. Aim: This study aimed to determine whether resourcefulness and positive thinking have a negative association with perceived stress among hospice and palliative nurses, and whether positive thinking moderates or mediates the link between resourcefulness and stress among hospice and palliative nurses. Method: A cross-sectional, correlational design was used to address these two aims. Results: A convenience sample of 86 hospice and palliative nurses (95% female) in the US completed an online survey. The results demonstrated that positive thinking and resourcefulness are useful predictors of stress reduction and help mitigate the effects of stress. Positive thinking did not mediate the relationship between resourcefulness and stress. Conclusion: Moderation analysis suggests that social resourcefulness may be especially helpful in reducing stress among hospice and palliative nurses with a low level of positive thinking.

Understanding primary palliative nursing education in undergraduate nursing programs.

BACKGROUND: Nurses are the largest segment of health care professionals and often the first one to interact with individuals about their health and illness. Ensuring nurses have the education to care for individuals with serious illness is essential to quality health care. The new AACN Essentials: Competencies for Professional Nursing Education delineates hospice/palliative/supportive care as one of four spheres of nursing care. Surveying undergraduate schools/colleges of nursing in Massachusetts about content pertaining to care of individuals with serious illness provides the foundation for a state strategy to ensure quality primary palliative education for undergraduate nursing students. METHODS: A Massachusetts statewide college/school of nursing survey approach to assessing primary palliative nursing education within undergraduate baccalaureate nursing curricula was performed from June 2020 to December 2020. Because the project was a collaboration with the Deans of the college/school of nursing, the survey identified the programs. RESULTS: Survey results revealed that only a small number of Massachusetts nursing programs are preparing nurses with specific and formal primary palliative nursing education. However, programs are open to support and resources. CONCLUSION: The survey provided information to inform a successful strategy to support primary palliative nursing education within Massachusetts undergraduate baccalaureate nursing curricula. A survey approach can serve as a model for other states.

The national AgeWISE pilot.

AgeWISE is a 6-month nurse residency program designed to prepare hospital nurses to meet the needs of older adults, a population that comprises nearly 50% of all US hospital admissions. The goal of AgeWISE, now being piloted in 12 hospitals in the United States, is to produce a tested and refined national model for building geropalliative care capacity among hospital nurses.

The Pediatric Palliative APRN: Leading the Future.

Pediatric palliative advanced practice registered nurses (APRNs) leaders are essential in advancing the field of pediatric palliative care. With expertise in pediatrics and strong advocacy skills for children, APRNs are well suited to lead interprofessional clinical teams, educational programs, community hospice and palliative organizations, policy changes, and research initiatives. Despite the prominence of their positions, there is a paucity of literature on pediatric palliative APRNs. This paper explores the leadership roles of the pediatric palliative APRN, offers resources to support leadership development, and showcases the importance of this role in various domains of pediatric palliative care.

Promoting Health Equity: Palliative Nurses on the Frontlines.

In May 2021, the National Academies of Sciences, Engineering, and Medicine released the Future of Nursing 2020-2030-Charting a Path to Health Equity. The report provides an in-depth analysis of the history and evidence of structural racism, the role of social determinants of health, and the role of nurses improving health equity in times of conventional care, disasters and crises, and public health emergencies. Palliative nurses are integral to impacting health equity for individuals with serious illness. Three strategies can help palliative nurses provide more equitable palliative care: 1) develop a more culturally sensitive practice and communication skill; 2) learn about the elements of social determinants of health to perform a simple Social Determinants of Health assessment as part of every patient's assessment; and 3) gather a list of community resources to help direct patients to resources.

Palliative Care: A Survey of Program Benchmarking for Productivity and Compensation.

Background: Palliative Care (PC) encompasses an integrated health care philosophy of care for individuals with serious illnesses and their families. Referrals to palliative care often come from other healthcare clinicians who lack the time and skill required to address the needs of the patient and their caregivers. At its heart, palliative care is individualized to the values, beliefs, and goals of the patient. The process of eliciting values, beliefs, and goals takes time and expertise, and correspondingly, palliative care is labor intensive. To date, there has been no concentrated focus on how to accurately capture the productivity or work of palliative care clinicians. As a result, there is not a universally accepted method of measuring the effort which includes impact, activity, composition, and productivity of a palliative care program. Objective: This paper reviews results obtained during a telephone survey of similar hospital-based palliative care programs on how they measure productivity. Currently, based on the survey, there are two focused methods for benchmarking: work relative value units (wRVU) and consult volume. This paper highlights the variability of wRVUs and the challenge of using them to compare different PC programs. Design: The design was an open-ended question telephone survey. Using the characteristics of our hospital program, the team created a composite of descriptions to consider for comparison. Then, various hospital-based palliative care teams were selected based on publicly reported data through Vizient, a national benchmarking organization. Based on a literature review, an open-ended question survey was created. These questions explored program composition, clinician productivity and performance benchmarks. Data was collected manually and stored in a confidential file. Result: Ninety-four programs were queried that met the following composite: (1) participated in Vizient program and (2) self-reported a hospital-based, inpatient palliative program. Forty-one programs responded to the request to participate. Of these, 32 programs consisted of facilities who had hospitalists who provided palliative care, but there was not a dedicated palliative care team. Nine programs had a dedicated palliative care team with clinicians who only practiced palliative medicine. Inquiry to these programs revealed that within these nine programs-two methods of capturing clinician productivity were used-five sites used a wRVU metric and four sites used a consult volume metric. Conclusion: Preliminary findings support the complexity of benchmarking PC programs against peer institutions with a standard productivity model based on the variability in program composition.

Defining Clinical Excellence for Palliative Care Specialists: A Concept Whose Time Has Come.

Experts in the field of palliative care in the United States (U.S.) have defined competence, or "good," mainly for programs, trainees, or providers of primary palliative care. Our interprofessional workgroup of palliative care specialists proposes that setting a standard for clinical excellence, or "great," applicable to palliative care specialists of all professions will elevate the field in the U.S. by providing an aspirational target usable for individual assessment and self-assessment, highlighting the common ground between team roles, and promoting a deeper understanding of teamwork, utilization, and productivity. We call for research that utilizes inclusive methods and broad representation of diverse voices to design a vivid, practical, and evidence-based definition of clinical excellence for palliative care specialists.

Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide.

CONTEXT: Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal. OBJECTIVES: 1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services. METHODS: Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce. RESULTS: Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships. CONCLUSION: An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering.

Using the Nurse Coaching Process to Support Bereaved Staff During the COVID-19 Crisis.

Nurses are confronting a number of negative mental health consequences owing to high burdens of grief during COVID-19. Despite increased vaccination efforts and lower hospitalization and mortality rates, the long-term effects of mass bereavement are certain to impact nurses for years to come. The nurse coaching process is an evidence-based strategy that nurse leaders can use to assist staff in mitigating negative mental health outcomes associated with bereavement. The End-of-Life Nursing Education Consortium brought together a team of palliative nursing experts early in the pandemic to create resources to support nurses across settings and promote nurse well-being. This article shares a timely resource for health systems and nursing administration that leverages the nurse coaching process to support bereaved staff in a safe and therapeutic environment.

Primary Palliative Care Clinical Implications: Oncology Nursing During the COVID-19 Pandemic.

The COVID-19 pandemic continues to affect the health and well-being of individuals and communities worldwide. Patients with cancer are particularly vulnerable to experiencing serious health-related suffering from COVID-19. This requires oncology nurses in inpatient and clinic settings to ensure the delivery of primary palliative care while considering the far-reaching implications of this public health crisis. With palliative care skills fully integrated into oncology nursing practice, health organizations and cancer centers will be better equipped to meet the holistic needs of patients with cancer and their families receiving care for serious illness, including improved attention to physical, psychosocial, cultural, spiritual, and ethical considerations.

The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines Domain 8: ethical and legal aspects of care.

In 2001, leaders with palliative care convened to discuss the standardization of palliative care and formed the National Consensus Project for Quality Palliative Care. In 2004, the National Consensus Project for Quality Palliative Care produced the first edition of Clinical Guidelines for Quality Palliative Care. The Guidelines were developed by leaders in the field who examined other national and international standards with the intent to promote consistent, accessible, comprehensive, optimal palliative care through the health care spectrum. Within the guidelines there are eight domains to the provision of palliative care. This article focuses on the last, but very significant Domain 8--Ethical and Legal Aspects of Care.

The Evaluation of a Palliative Care Advanced Practice Nursing Externship.

A growing population of persons with a serious illness will place higher demands on health care professionals to provide the palliative care needed. A Palliative Care Advanced Practice Registered Nurse (APRN) Externship was developed and implemented as a novel way to increase access to palliative care with the potential to be replicated in multiple locations. Two APRN cohorts with a total of 10 APRNs participated in a 1-week educational program, including both classroom and clinical experiences, in 1 such site. The effectiveness of the program was evaluated by participants through an electronic survey and debriefings. Active learning experiences included role play, case studies, and clinical observation and were rated as highly valuable by participants. An important theme concerning the validation of current practice was identified. Future externship programs should be refined by incorporating participant feedback and continuing to use a variety of techniques to engage learners with diverse learning styles.

Improving Support for Family Caregivers of People with a Serious Illness in the United States: Strategic Agenda and Call to Action.

Background: An estimated 30% of the adult American population are caregivers and many of the people they support live with serious illnesses. Caregivers provide an average of 20 hours of services per week and are heavily involved in assisting with activities of daily living. This input represents considerable economic value to the health care system and to the well-being of communities. However, the impact of the burden on caregivers is considerable with negative outcomes on their physical, psychological, social, and financial well-being. The current landscape of caregiver policy in the United States is not well coordinated and does not meet the needs of this population. Objective: To develop a strategy to enhance the future of family caregiver support of people with serious illness within the United States. Methods: (1) Creation of project steering and key stakeholder groups; (2) survey and in-depth interviews with key stakeholders; (3) review of key family caregiver reports, systematic reviews, policies, and financial initiatives. Results: A strategy to provide clear direction to enhance the future of family caregiver support of people with serious illness within the United States was developed focusing explicitly on policy, research, training, service delivery, and public engagement. Conclusions: The strategy is an initial step aimed at enhancing support for family caregivers of people living with serious illness. It outlines key recommendations and a "call to action." Subsequent work will be needed on prioritization of tasks, gaining buy-in at all levels of the policy-making apparatus, operationalization, and implementation.

An evidence-based nurse residency program in geropalliative care.

As U.S. baby boomers age and the older population doubles by 2030, unprecedented numbers of older adults will need and benefit from nursing care that is evidence-based and tailored to their needs and preferences. To address this need, Massachusetts General Hospital developed the RN Residency: Transitioning to Geriatrics and Palliative Care program. Guided by two national curricula, the RN Residency program was designed to expand the disease model of geriatrics to a functional, emotional, and social perspective of aging, in which palliative care is an integral component. This article describes the RN Residency program, which was designed to improve the effectiveness of nursing assessment, interventions, and outcomes for older adults and their families.