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The Advanced Practice Registered Nurse in Outpatient Palliative Cancer Care 

The Advanced Practice Registered Nurse in Outpatient Palliative Cancer Care
Chapter:
The Advanced Practice Registered Nurse in Outpatient Palliative Cancer Care
Author(s):

Barbara Reville

DOI:
10.1093/med/9780190204747.003.0012
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Key Points

  • Leaders in the fields of palliative care and oncology advocate full integration of palliative care into usual oncology care.

  • Models of palliative care outside the acute care setting have demonstrated benefits in the domains of symptom management, psychosocial and spiritual distress, and support for patients at illness transition points.

  • Advanced practice registered nurses (APRNs) have a stake in strategic planning for outpatient services alongside administrators and oncology clinicians.

  • The therapeutic relationship between the palliative care APRN and patients and families is the focal point of patient-centered palliative nursing.

Introduction

Advanced practice nursing at the intersection of outpatient oncology and palliative care is the focus of this chapter. The chapter opens with a review of relevant evidence and national directives to integrate outpatient oncology and palliative care early in the illness course. Next, the different conceptual models for palliative care in oncology settings are explained. Finally, key categories of nursing intervention to relieve patient suffering, maintain collaborative relationships with the oncology team, and measure outcomes of practice are presented.

Palliative care is universally recognized as a pillar of comprehensive cancer care throughout the illness trajectory, not just at the end-of-life. This view has evolved in recent years in response to emerging evidence. Currently, leaders in the fields of palliative care and oncology advocate full integration of palliative care into usual oncology care.1,2,3,4,5,6,7 Ferris and colleagues defined “palliative cancer care” as:

[T]‌he integration into cancer care of therapies to address the multiple issues that cause suffering for patients and their families and have an impact on the quality of their lives. Palliative cancer care aims to give patients and their families the capacity to realize their full potential, when their cancer is curable as well as when the end of life is near.6(p 3055)

As the nature of cancer becomes increasingly chronic, most oncology care occurs in the outpatient or community setting, not the acute care setting.5 While palliative care for cancer patients and families in the hospital or hospice setting is widely available at U.S. cancer centers, specialty palliative care services for outpatients are less common.7,8 Specialty outpatient practice represents a “new frontier” for palliative care professionals to operationalize longitudinal care over the illness course rather than primarily managing acute issues during an inpatient encounter.2,4,5,7(p 823) Models of nonhospice palliative cancer care outside the acute care setting have demonstrated benefits in the domains of symptom management, psychosocial and spiritual distress, and support for patients and families at transition points of the illness.1,3,9,10,11,12,13,14,15,16,17

While there is strong support among oncology and palliative care organizations for collaboration, there is no standard model of care delivery for outpatient palliative cancer care.3,6,8,18 However, innovative endeavors by palliative care physicians and APRNs have demonstrated the feasibility of outpatient practice models, patient and provider satisfaction, and positive patient outcomes.10,11,14,15,16,17,18,19,20,21

The APRN is well suited to provide care that is complementary to physician management in nonhospital settings.22,23,24,25,26 Nursing’s practice of whole-person care aligns with palliative care’s patient- and family-centered focus.27,28,29 The Hospice and Palliative Nurses Association’s position statement declares that the APRN is “uniquely qualified and positioned to address the myriad needs of individuals facing life-threatening, progressive illness” in any primary care setting.30(p 1)

According to the Oncology Nursing Society, the scope of practice defined for oncology APRNs encompasses attention to the palliative care needs of patients and families.31 Therefore, the APRN with education as a clinical nurse specialist, a nurse practitioner, or a blended role and clinical skills in oncology can provide primary palliative care of the oncology patient.23,26,27,28,29,30 However, specialty training and certification as a hospice and palliative advanced practice registered nurse is required for expert-level palliative care practice.23,26,28,29,30,31

Integration of Oncology and Palliative Care—A National Priority

The professional oncology community aspires to full palliative care integration into comprehensive cancer care by the year 2020.6,8 National opinion leaders and professional groups in oncology joined the groundswell of support for integrative care models and new standards for quality cancer care. While palliative care awareness is growing, timely referral for and access to services remain inadequate.2,32

According to the Institute of Medicine’s report Dying in America, our increasingly aging and culturally diverse populations who are living with advanced serious illness deserve access to palliative care.32 The Institute of Medicine charged the healthcare professions to train clinicians to adopt palliative care’s person and family focus, to encourage more frequent clinician-initiated communication about end-of-life decisions with patients, and to build more basic palliative care training programs for doctors and nurses. The report recommended that healthcare systems develop better access to integrated palliative care models and expert-level palliative care providers, offer incentives for reducing hospital admissions and costs, and ensure quality, efficiency, and information transfer.

The National Comprehensive Cancer Network’s (NCCN) clinical guidelines reflect the profession’s commitment to full integration of care.33 The guidelines direct institutions to develop programs whereby patients can access credentialed palliative care professionals, including APRNs, concurrent with oncologic care. Further, these programs should be monitored for quality outcomes.

The Evidence for Outpatient Palliative Cancer Care

Several major findings galvanized the oncology field’s perception that palliative care can improve the cancer patient’s illness experience in a variety of ways from the time of diagnosis.1,5,9,10,14,15,17,18 While the following reviews are not exhaustive, they provide an historical overview of this body of work. The cumulative results build a strong case for earlier involvement of palliative care in the outpatient setting.

In 2009, Bakitas and colleagues reported on a nursing-led intervention involving multiple patient education, psychosocial support, and problem-solving sessions followed by telephone case management for a rural population of outpatients from time of diagnosis with stage III or IV cancer diagnoses until death.14 The study intervention ran concurrently with usual oncologic care. Quality of life, symptom intensity, and mood were measured at baseline, at 1 month, and every 3 months while on the study. The electronic medical record supplied data on use of the hospital, intensive care unit, and emergency department as proxy measures for use of aggressive care at the end-of-life. The patients in the study group reported higher quality of life and better mood than the controls, without a difference in mortality or use of acute care services.

Another nurse investigator, Prince-Paul, led a pilot study to explore the effects of concurrent care by a palliative APRN in a community oncology setting.15 Similar measures as in the aforementioned Bakitas study for physical and psychosocial symptoms, including spiritual well-being and use of healthcare services, were measured in a sample of advanced cancer patients. There were no significant differences between the group who received palliative APRN care and those who did not on symptoms, quality of life, depression, or spiritual well-being. However, patients in the APRN group had lower mortality at 4 months and were significantly less likely to be hospitalized. This work affirmed the value of the APRN and suggested a feasible, cost-effective model for centers without resources to hire an entire team.

A rising number of cancer survivors are alive today.5 The survival of nearly 12 million Americans with a cancer history lends credence to progress in anticancer modalities and care. While most of these individuals encounter healthcare providers outside the acute care setting, many are coping with symptoms of a physical, psychological, or spiritual nature stemming from their cancer illness. These community-dwelling cancer patients are not eligible for hospice care but may need palliative care.

Data analyses on 4,980 cancer patients seen by palliative care providers offered an overview of nonhospice palliative care needs in the ambulatory setting.5 Patients’ diagnoses were mostly solid tumors, including lung and gastrointestinal, and some hematologic cancers. Forty percent of the sample required hospital care in the previous 6 months, 49% had performance status indicative of limitations in daily function, and 40% had substantial functional decline. Most had a provider estimate of survival of less than 6 months, and 88% reported fair or poor quality of life. One-third of the sample did not have a healthcare surrogate identified and 97% had not completed a physician order about end-of-life preferences. As to symptoms, 95% had at least one symptom and 67% had three or more symptoms. In summary, these outpatients were encountering palliative care when in decline without earlier attention to symptoms or decision making. These findings suggest that earlier intervention during the disease course is warranted.

Muir and colleagues reported on the effect of adding one half-day palliative care clinic alongside a busy community oncology center on quality outcomes, referral volume, provider satisfaction, and time saved for oncologists.18 Over the first 2 years of clinic operation, the investigators noted a decrease in patients’ symptom severity scores on the Edmonton Symptom Assessment System, high provider satisfaction, and an 87% increase in referrals. The issue of saving specialty cancer resources is germane because the existing oncologist workforce is insufficient to meet the growing need as the American population ages.34

In 2010, Temel and colleagues added impressive evidence to the emerging case for early outpatient intervention in advanced cancer.10 In this trial, newly diagnosed lung cancer patients with metastatic disease were randomized to receive usual cancer care with or without early palliative care provided by board-certified palliative care physicians and APRNs. The researchers measured quality of life using a lung-cancer-specific tool (Functional Assessment of Cancer Therapy-Lung) and mood at baseline and 3 months. They searched electronic medical records to assess use of aggressive end-of-life care (use of chemotherapy within 14 days of death, no hospice care or hospice enrollment within 3 days of death), documentation of end-of-life preferences, and survival. Significant findings among the intervention group were higher quality-of-life scores, less depression, less aggressive care at the end-of-life, and a remarkable 2.7-month survival advantage.10 The accumulated evidence in favor of palliative care had reached the tipping point.1

Policy Shift Favoring Early Palliative Care for Cancer Patients

In 2012, the American Society of Clinical Oncology responded to the mounting evidence in favor of palliative care by directing its members to eschew the perception that palliative care is merely end-of-life care.1 Further, they advised oncology professionals to consider involving palliative care early in the illness for patients with metastatic cancer and/or multiple symptoms. The National Cancer Institute (NCI) articulated the full continuum of palliative care as follows: “palliative care is given throughout a patient’s experience with cancer.”35,36

The Commission on Cancer (CoC) of the American College of Surgeons added a new palliative care standard as a requirement for hospital cancer program accreditation in 2012.3,37 This standard requires that “palliative care services are available to patients either on-site or by referral.”37(p 70) Table 12.1 lists the palliative care services that fulfill the CoC standard. An interdisciplinary team, including a specialty-trained and/or certified hospice and palliative medicine physician and nurse, along with other professionals, is recommended.28,29

Table 12.1 Commission on Cancer: Palliative Care Program Requirements

Interdisciplinary, team-based care of patient and family

Pain and symptom management

Communication among providers, patients, family

Continuity of care across all services and settings

Provision of spiritual comfort

Provision of psychosocial support for patient and family

Provision of bereavement support to families and professional care providers

Conversation about hospice care if patients have poor prognosis or at the end-of-life

Sources: Commission on Cancer (2012), reference 37; American College of Surgeons (2011), reference 3; Fox (2014), reference 29.

The broadening of the oncology profession’s perception of palliative care beyond an end-of-life care paradigm helped set the stage for expansion of outpatient models of care in cancer centers and the community.4,5,7,18,34,38 In 2010, a survey of NCI-designated cancer centers revealed that most (98%) had some palliative care service (e.g., a palliative care physician, a consultation team, or a palliative care clinic) as compared to only 78% of non-NCI-designated centers.8 Nurses were represented on palliative care teams in 47% of all programs in the sample, although level of training or certification was not reported.

Outpatient palliative care clinics specifically for oncology patients were twice as common among NCI-designated centers but were still available for only about 66% of centers.8 The oncology clinic was the site of palliative care delivery in 23% of the centers with outpatient care. Growth of outpatient palliative cancer programs that need APRN providers can be anticipated in coming years.4

Another survey of outpatient palliative care targeted 12 academic medical centers where palliative care was well established.38 Most were not full-time operations and reported nearly 500 patient visits annually, usually referred by oncologists. Team members most often included physicians. More than half of the programs reported APRN staff, followed by social workers (45%) and registered nurses (36%). Funding came from a mixture of billing revenues and institutional support.

Models of Outpatient Palliative Cancer Care: Opportunity and Challenge

The use of language to communicate what “palliative care” means to oncology providers and patients has evolved along with the field.2,4,11,38 The APRN practicing in an oncology setting should be mindful of both the attitudes and adoption of palliative care conveyed by word choices. In some settings the term “palliative care” is avoided altogether. For example, “simultaneous care model” implies that palliative care is not an alternative to oncologic care.2,7 The term “supportive care” is frequently used synonymously with palliative care and is favored by oncologists wary of the stigma of the latter term.2,11,39 The term “supportive care” can also connote early intervention closer to the time of diagnosis of metastatic or highly symptomatic cancer.

There are three principal models of outpatient palliative care associated with a health system or hospital: a stand-alone clinic, a co-located clinic, and an embedded clinic.4 Definitions for each are listed in Table 12.2. These models are advantageous for cancer centers committed to support onsite palliative care services and earn CoC accreditation.40 More than one model may operate successfully within a single institution.11

Table 12.2 Definitions of Outpatient Palliative Care Clinic Models

Clinic Model

Referral Sources

Operations

Stand-alone clinic

From anywhere in health system, depending on scope of services

Separate palliative care administrative structure and cost center, space, staff, scheduling, and billing

Co-located clinic

Predominantly from host specialty but can accept from other specialties

Shared space and services with host from a specialty that frequently consults palliative care. Responsibility for operational costs is negotiable.

Embedded clinic

Collaboration with host clinic for exclusive, onsite palliative care services. Referral process and scope of practice well defined.

Host clinic assumes all operational costs.

Sources: Barbour et al. (2012), reference 40; Bruera & Hui (2012), reference 11.

APRNs have a stake in strategic planning for outpatient services alongside administrators and oncology clinicians.29 Items to negotiate include responsibility for clinic costs, space and time allotments for palliative care providers, billing revenue flow, and referral processes.4,11,40 The CoC palliative care services standard requires that a palliative care team member join the institution’s cancer committee.37

Clear communication about the nature and scope of the palliative care involvement between palliative care and oncology teams is essential for fruitful collaboration.18 In a consultant role, the palliative care provider renders clinical opinions, providing only recommendations.40 In a co-management role, palliative care personnel see patients on a “limited” basis to manage specific issues (e.g., symptoms) at the request of the oncology team.11,18 A primary care role involves ongoing or longitudinal care involvement for higher-demand patients (e.g., early intervention palliative care).41,42,43 In any scenario, patients can be seen individually by the palliative care provider or jointly with the oncology team.40 A uniform policy is advisable to clarify provider accountability for patient follow-up and medication prescribing, especially for opioid use.

Challenges to realizing integrated palliative cancer care can hamper a program’s success either at its outset or during growth.5,11,24 First, there is limited evidence on how to best integrate primary and secondary palliative care and when to involve specialty-level palliative care.5,44 Second, APRN practice may be subject to limitations due to regulations or institutional policy.

Primary palliative care skills are essential to all oncology clinicians, including oncology APRNs.44 Oncology teams consult specialty-level palliative care providers for more complicated or refractory symptoms, complex psychosocial-spiritual issues, conflict situations, or ethical dilemmas. Without a clear triage or referral schema, palliative care providers can be overwhelmed by too many consults or, conversely, can be underused due to confusion about when to initiate consults.16

Palliative care programs use referral criteria or “triggers” as a process of care that educates providers about when to consult palliative care.33,45 Table 12.3 lists oncology referral criteria for palliative care. These can also be applied to screen incoming consults to ensure that requests are appropriately directed to palliative care.40,44

Table 12.3 Triggers for Palliative Care Consultation

Disease Factors

Patient Factors

Hospitalization Factors

Disease progression during treatment

Substance abuse history

≥2 admissions in 3 mos.

Limited treatment options

Cognitive impairment

≥5 days in ICU without evidence of progress

Decline in functional status in last 60 days

Limited social support

Frequent emergency department visits

Life expectancy ≤ 6 months

Need to clarify treatment decisions or goals of care

Advanced comorbidities

Request for palliative care

Uncontrolled symptoms

Language barriers

  • Complex or refractory pain

    • - Escalating opioid use

    • - Neuropathic pain

Uncontrolled psychosocial or spiritual distress

Sources: National Comprehensive Cancer Network (2014), reference 33; Walling et al. (2008), reference 54; Reville et al. (2013), reference 45.

Palliative APRNs may encounter practice barriers due to variations in states’ scope of nursing regulations, such as limits to independent practice without physician supervision, or prescriptive authority.24 Lower reimbursement for services compared to physicians may drive institutional decisions about practice model, or referral protocols may limit APRNs from initiating new consults.18 To overcome such barriers, it is important for APRNs to contribute to planning structures and processes of outpatient care.

Case Study Part 1

Mack, a 45-year-old married landscaper with cancer at the base of the tongue, developed severe neuropathic facial pain during chemoradiation. The pain became refractory to his home pain regimen of extended-release oxycodone. During an oncology clinic visit, the team consulted the palliative APRN associated with their clinic to co-manage Mack’s pain and see the patient during future oncology visits. The palliative APRN recommended an opioid rotation from oxycodone to methadone and prescribed a daily bowel regimen.

Unique Role of the Palliative APRN

APRNs provide palliative care as expert clinicians, educators, leaders, administrators, and researchers.23,24,26,27,28,29,30 Their unique role combines a holistic perspective on human responses to serious illness with the art of creating a healing presence and the use of evidence-based interventions to prevent, diagnose, and ameliorate the suffering of patients and families.27 Guidelines for APRN intervention can be found in The Clinical Practice Guidelines for Quality Palliative Care and the Hospice and Palliative Nurses Association’s APRN competencies.46,47

Nurses often work alongside non-nursing providers. Whether the palliative APRN is the only nurse on a palliative care team or the sole palliative care clinician in an oncology clinic, it is important to maintain “a nursing orientation.”27(p 108) When nurses “unconsciously use a medical or institutional model as their perspective for organizing care,” they limit their potential contribution.48(p 27) The key principles of advanced nursing practice are reviewed in the following sections.

Establishing and Maintaining Relationships

The palliative APRN in the outpatient oncology setting must establish “linkages” or collaborative relationships and observe proper consultation etiquette to be successful.7(p 828) Oncologists and the oncology team ultimately decide the timing and extent of palliative care consultation.2,11,18 Should other issues outside the consult’s scope arise, the APRN must communicate these to the oncology team before proceeding to an extensive consultation. For example, a request for help treating a symptom is a typical limited consultation. A more extensive consultation request might include broaching goals of care and support for a hospice transition. Clear communication establishes and maintains trust and respects the oncology care plan and role boundaries.

The therapeutic relationship between the palliative APRN and patients and families reflects the patient-centered approach of nursing and palliative care.15,27,48 Prince-Paul described how a palliative APRN embedded in oncology practice accomplished this: “The [palliative APRN] established a trusting relationship with the patients through clinical expertise, repeated contact and communication, an active presence, and emotional support; this connection may have ultimately improved outcomes.”15(p 26) Over time, “an emotional climate” for sharing of psychological and spiritual concerns and regrets offers patients comfort without altering their situation.49(p 164)

Jacobsen and colleagues advocate “continuity outpatient palliative care,” a concept for long-term palliative care presence that builds a trusting provider–patient relationship.43(p 1) This is consistent with the aforementioned primary care role and is ideal for early palliative care involvement. In this scenario, initial patient encounters focus on building rapport and assessing symptom or coping issues.41,42 Over subsequent patient encounters, the palliative APRN should ask about life prior to the illness and the cancer’s impact on emotions and should intervene as necessary with advice on adaptive coping strategies (e.g., meditation, problem solving, or gratitude).49,50

The APRN should elicit the patient’s illness understanding, his or her expectations for cancer treatment, and preferences for receiving frank prognostic information.49,50,51 Assessing the role of family caregivers in medical decision making is preliminary to talks about advance care planning and, eventually, code status and end-of-life wishes. As the illness evolves or with clinical setbacks, the trust and the caring foundation the palliative APRN has created with the patient allows access to more sensitive topics. Ongoing communication about key patient disclosures with the referring oncology team is advised. A successful joint care plan requires alignment of information the patient hears from both oncology and palliative care providers.

Case Study Part 2

Over the course of subsequent visits with Mack, the palliative APRN ascertained that his goals were to remain home with his wife and 3-year-old son, Mack, Jr., to continue working, and to pursue any and all treatment options. A recent hospital stay was very stressful for Mack’s wife, who felt torn between remaining at the hospital with Mack or home to care for Mack, Jr. The palliative APRN communicated these concerns to the oncology team and suggested a visit with the oncology social worker to discuss coping strategies with Mack and his wife, and to consider a home care referral.

Practicing Essential Communication Skills

The palliative APRN in the oncology clinic uses his or her communication expertise to establish and maintain relationships as described above and during serious conversations at illness turning points.43,49,51,52,53 While the primacy of this practice must be stated, full discussion of APRN communication skills is outside the scope of this section.

Oncology referrals to palliative care to address goals of care are recommended at transition points in the illness and when treatment options are dwindling.1,33,54 These “sentinel events” include (1) admission to an intensive care unit; (2) use of mechanical ventilation; (3) metastasis to the central nervous system; (4) start of a new chemotherapy regimen; (5) need for hemodialysis; (6) placement of a cardioverter-defibrillator; (7) placement of gastric tube; and (8) impending major surgery.54(p 3900) Psychosocial or spiritual shifts in awareness of the patient’s inevitable death generate equally traumatic transitions.25 At these turning points, a goals-of-care discussion or family meeting is warranted.

Goals-of-care discussions ideally involve the patient and family and the oncology team.15,18 Social work or pastoral care colleagues bring another perspective and considerable communication skills, especially for psychosocial distress, existential questions, or conflict. The palliative APRN may facilitate the meeting or provide specific information, such as hospice eligibility.

Case Study Part 3

Four months after initiation of chemoradiation, Mack was hospitalized with delirium, dehydration, weight loss, worsening functional status, and acute renal dysfunction. Imaging studies indicated disease progression. The delirium improved with intravenous hydration and opioid dose adjustment. However, the oncology team had no further treatment options and felt hospice was Mack’s best option.

The oncologist scheduled a family meeting soon after discharge with Mack, his wife, the oncology social worker, and the palliative APRN. Mack was emphatic in his desire for more chemotherapy in hopes of life prolongation. The oncologist warned of organ dysfunction and side effects, as well as low likelihood of longer life.

The palliative APRN recalled Mack’s initial goal to remain at home with his family and asked if this was still his foremost goal. The APRN expressed concern that more treatment might cause complications and need for hospitalization. Mack replied that he preferred never to return to the hospital. The conversation turned toward an elaboration of Mack’s wish for death at home with support for his family and attention to his comfort. He did not want life-prolonging measures like cardiopulmonary resuscitation. The social worker outlined how hospice care aligned with Mack’s wishes and would reduce his wife’s stress. A hospice referral was made. Mack died peacefully at home 4 weeks later.

In this chapter’s case study, a limited symptom management consult evolved following sentinel events in the illness course to an extensive goals-of-care conversation. The APRN’s co-management role with oncology complemented disease management and supported the patient’s and family’s quality of life. The APRN’s caring relationship over the illness course facilitated a transition in goals of care.

Screening for Pain and Non-pain Symptoms

The NCCN guidelines instruct oncology teams to screen all patients for uncontrolled symptoms, advanced comorbidities, poor performance status, and specific oncologic problems (e.g., hypercalcemia, spinal cord compression, or cachexia).33 Common symptoms to assess include pain, dyspnea, anorexia, nausea and vomiting, constipation, fatigue, sleep disorders, and delirium. A management plan is needed for any issue identified during initial assessment.

Symptom screening tools aid clinicians performing comprehensive evaluations, reduce variations in care, and supply baseline data for quality measures. The palliative APRN should elicit symptom intensity, quality, associated symptoms, and level of distress using tools validated in the oncology population or in common use by the oncology team.55 Examples include the Memorial Symptom Assessment Scale, Edmonton Symptom Assessment System, the 0–10 visual analogue scale, and the McCorkle Symptom Distress Scale.5 Management strategies for common symptoms can be found elsewhere in this text.

Coping Support and Distress Management

The CoC cancer program accreditation standards require universal screening for psychosocial distress during an initial oncology clinic visit by clinician interview or questionnaire.3,37,56 Should patients indicate moderate or high distress, evidence in writing of an in-depth assessment, plan of care, or referral is required. Any member of the oncology team, including psychosocial-spiritual care providers, can complete this assessment. Each program must develop its own process of care to comply with this standard. Smith and colleagues used an electronic patient report system that triggered referrals in outpatient oncology.21

The NCCN guidelines recommend palliative care referrals for distress scores above 4 on a 0-to-10 scale.33 Other criteria for referral include evidence of caregiver deficits, poor social support, family conflict, spiritual concerns, and risk factors for complicated grief. The palliative APRN can help the oncology team by performing in-depth psychosocial assessments that comply with the clinic standard. Assisting patients with coping is consistent with the APRN role, as are medication management and referral to psychosocial and spiritual professionals.

Staff distress can occur in high-volume oncology settings, especially among staff exposed to cumulative patient losses.57 The palliative APRN can help to identify compassion fatigue and moral distress and collaborate with the oncology team on resources to support staff.

Promoting Care Continuity and Coordination

A team approach shares the work of caring for the myriad physical and psychological concerns of patients with serious illness. The palliative APRN can benefit from networking about services within the institution and in the community that provide cancer care—for example, home care and hospice agencies, physical rehabilitation services, specialists in interventional pain modalities, nutrition professionals, mental health resources, and others.40

The palliative APRN serves as a bridge between the disciplines in the interest of full integration between oncology and palliative care. Ideally, the APRN communicates regularly with his or her inpatient palliative care colleagues to learn about incoming referrals from the hospital, to track progress of hospitalized patients, and to provide collegial support and education. At the same time, the APRN can participate in oncology clinic forums for education, quality improvement, and patient care coordination.

Measuring Outcomes for Quality and Sustainability

The Joint Commission awards advanced certification to palliative care programs that establish data-driven performance improvement processes to improve and validate operations. Measures must be evidence-based and must include patient satisfaction feedback and a plan to address sentinel events.58

It is best if outcome measures align with oncology priorities and use data already collected in routine practice or processes. For example, data on physical symptoms using standardized scoring systems are useful to measure improvement from before to after consultation.6 Psychosocial measures include quality-of-life and depression scores, caregiver burden and perceptions of care, and distress scores.18 Indicators of acute care utilization (e.g., readmission rates, emergency department visits, and timing of hospice enrollment prior to death) show the impact of palliative care integration.10,11,19 Operational measures (e.g., consult volume, wait time to see new referrals, professional fee revenues, or time saved for oncologists) will interest stakeholders and help anticipate staffing needs.40 Palliative care providers can also survey their oncology colleagues for feedback on the collaboration.

Summary

Palliative APRNs practicing in oncology outpatient settings are leading the way for full integration of these disciplines into comprehensive, high-quality cancer care. Reports from many innovative endeavors have demonstrated beneficial patient outcomes and institutional goals.

There are various models for care delivery. For patients who need specialized palliative care input, the palliative APRN may consult, co-manage, or play a primary care role in collaboration with the oncology team. Ongoing communication is essential to establish and cultivate linkages to referring oncology providers.

The APRN is advised to contribute to strategic assessment, planning, and evaluation of new programs to ensure that they address gaps in care and adhere to national practice standards. Finally, APRNs should advocate for structures and processes of care that prioritize patient- and family-centered care and support an expanded scope of advanced nursing practice.

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