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The Advanced Practice Registered Nurse in the Geriatric Outpatient Setting 

The Advanced Practice Registered Nurse in the Geriatric Outpatient Setting
Chapter:
The Advanced Practice Registered Nurse in the Geriatric Outpatient Setting
Author(s):

Joan E. Dacher

and Sherrie Murray

DOI:
10.1093/med/9780190204747.003.0015
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Key Points

  • A growing number of older adults in the United States are living longer, but with multiple chronic illnesses and disabilities. These result in frailty, high illness burden, and high healthcare utilization at the end-of-life. Palliative advanced practice registered nurses (APRNs) can play a role in the care of these older adults.1

  • The principles of geriatric care, in tandem with The Clinical Practice Guidelines for Quality Palliative Care developed by the National Consensus Project for Quality Palliative Care,2 provide guidance to the APRN caring for medically complex older adults in the outpatient setting, with an emphasis on patient- and family-centered care delivered by a coordinated care team.

  • APRN practice in the geriatric outpatient setting will include the delivery of primary care, care coordination, interdisciplinary team communication, assisting patients to navigate the healthcare system, advocacy, and patient education, while providing evidence-based practice.3

  • Among the common problems encountered by the APRN working with geriatric patients in the community setting are fatigue, sleep disturbances, depression, anxiety, grief, cognitive impairment, disability or change in functional status, polypharmacy, and post-hospitalization medication adherence.4,5,6,7

Introduction

The appropriateness of palliative care for older adults is evidenced by the demographic profile of older Americans as well as the data that speak to the efficacy and cost of the care provided. A model for providing palliative care is well-established and can be found in the nexus between the principles of palliative care and gerontology. There is a strong, evidence-based case for ensuring that older adults have access to palliative care. With the appropriate education, knowledge, and skills, APRNs are well situated to play a pivotal role in providing palliative care to older adults in outpatient settings.

The growth of the total numbers of older adults in the United States, their state of health with regard to chronic illness and disability, and the stated desire of this population to live out their lives in the community make a case for ensuring that older adults have access to palliative care. Since 1900, the population aged 65 and older has grown faster than other segments of the population, in part due to increased longevity, the result of medical advances. Projecting into the future, the growth in this segment of the population will continue to expand.8 With longevity come issues of disability, chronic illness, and access to appropriate care. Increased longevity is a mixed blessing. It is the result of health improvements but in turn results in frailty, a high illness burden, and heavy use of healthcare at the end-of-life.

The prevalence of acute and chronic health conditions increases with age. According to the U.S. Census Bureau, overall, individuals 65 and older represent 50% of all cancer diagnoses in the United States.1 Dementia, specifically Alzheimer’s disease, disproportionately affects older adults, and the rate increases with age.1 Functional limitations and disability are associated with advanced age. The APRN working in this area should be knowledgeable about the physiological changes of aging and how they contribute to limitations and disabilities. Among the common issues confronting the APRN working with older adults with complex serious illness in the community setting are fatigue, sleep disturbances, depression, anxiety, grief, cognitive impairment, and disability or change in functional status.4 Polypharmacy and post-hospitalization medication adherence are risk factors for worsening of disease, repeat admission, and death.5,6,7 Injury prevention is a critical preventive health need. A fall can be a catalyst for a sequence of events that contribute to an increased demand for healthcare, a loss of independence, and a need for pain and symptom management. Falls can be the outcome of numerous clinical factors, including age-related changes in postural control, gait, and vision, diseases that affect sensory input, musculoskeletal changes, and medication use.9 The clinical picture is further complicated by the patient’s living environment. Each of these is a focal area for assessment by the APRN.

Ethics of Care for Older Adults in the Community Setting

Decision making in regard to the appropriate course of care for older adults living with acute and chronic illness is complex. At the macro or systems level of consideration, attention must be given to the efficacy of care, resource utilization and deployment, and the prominence of cure over care.10 Heavy use of healthcare does not result in better care, greater patient satisfaction, or increased ability to remain independent.4,5 The increased prevalence of chronic illness is significant; management of chronic illness has emerged as the expected healthcare need among older adults. When working with the older adult in the community, questions emerge about the appropriate use of services.11,12 Management requires an approach that takes into account pharmacologic intervention, physical response and symptoms, safety, mobility, social and emotional well-being, and the ability to maintain the highest possible level of functional capacity. These concerns prompt ethical questions about what constitutes appropriate care for older adults, as well as the circumstances in which care is delivered. Care for community-dwelling older adults is shifting toward becoming more responsive and coordinated, with a focus on offering opportunities for participation in advance care planning. The APRN working with this population must bear in mind the larger ethical questions and the ways they drive patient’s and family’s decisions. This establishes a context for care that is especially important for geriatric patients, who are at higher risk for morbidity and mortality.

Health Policy and Support for Palliative Care for Older Adults

While the 2010 Patient Protection and Affordable Care Act (PPACA) is an opportunity to address issues of chronic illness, quality of care, the rising cost of care, and all issues that disproportionately affect older adults, it falls short in addressing access to palliative care. In its initial inceptions, the bill included support for provider reimbursement for an advance care planning conversation with Medicare patients. Amid criticism and concerns about healthcare rationing and Medicare “death panels,” portions of the act were omitted in the final version; policy changes related to end-of-life care are absent from the final document, and thus the opportunity to address a critical need of healthcare in the United States was lost.13 Other provisions of the PPACA offer the opportunity to address quality issues for which palliative care could be of benefit.14

Money allocated to reduce the cost of care and the move toward bundled care costs have resulted in affordable care organizations (ACOs)15 and primary care medical homes (PCMHs), two models designed to coordinate care for patients with complex care needs and to provide support for the transition of care from one setting to another.16 The APRN in the outpatient geriatric setting who is working within the larger ACO or the PCMH can play a critical role in delivering care to the older adult with comorbidity and advanced chronic illness, especially in the transition to the community, and in avoiding readmission and extraordinary interventions for the management of complex comorbidities. Some states have recognized certified Medicaid provider nurse practitioners as appropriate to take on the leadership of PCMHs.17 The goal of the ACO is to reduce fragmented and uncoordinated care18 through the use of an integrated team for care delivery. Care is best delivered to older adults in the context of a team and a coordinated approach to quality and safety. The APRN is an ideal partner for this, and the geriatric clinic provides a setting in which to support these goals and meet the needs of older adults with complex medical conditions.

ACOs and PCMHs are conceptually aligned with palliative care as well, offering additional opportunity for the APRN working in the geriatric clinic to integrate concepts of palliative care into practice. The literature suggests that an integrated model of palliative care can result in cost savings and is well-positioned to assist in these models of healthcare delivery. Palliative care teams have shown they can align services to meet patient and family needs while employing existing resources and reducing cost burden,19 presenting an opportunity to incorporate palliative care as a viable model for the development of ACOs and PCMHs.

The APRN’s Role in Providing Palliative Care for the Older Adult

This is a critical juncture for continuing to expand the role of the APRN in palliative care for older adults in the outpatient or community setting. Funding exists for educating APRNs in palliative care through the educational arm of the PPACA. Nurse practitioners are needed across the continuum of care from inpatient, nursing home, and community/outpatient settings.13 The use of APRNs in these settings is cost-effective, as suggested in Bauer’s study of nurse practitioners in nursing homes,20 and can be effectively delivered using a collaborative practice model with other health professionals.21 Nurse practitioner co-management of geriatric clients is similarly shown to have better outcomes.22 Evidence supports the value and role of geriatric clinical nurse specialists in improving patient outcome and providing cost-effective care.23 The geriatric clinical nurse specialist is educated to work in a large scope of practice in direct and indirect roles, including patient education, diagnosis and treatment of symptoms, staff education, program and policy development, and quality and safety improvement.24 A strong case has been made for the importance of the generalist, primary care, or acute care APRN to have the knowledge base in palliative care to best serve older adult clients wherever they are encountered.25

The Nexus Between Gerontology and Palliative Care

There is ample guidance for the APRN engaged in delivering palliative care to older adults. Gerontology offers a comprehensive approach to the study of aging, and geriatric medicine as a subset of gerontology provides practitioners with recommendations and principles for comprehensive assessment and treatment. Such assessment and treatment address all aspects of the older adult’s life: physical, cognitive, psychosocial, financial, and environmental conditions that converge and drive the need for care. Often comprehensive assessment is conducted by an interdisciplinary team and treatment is offered within the context of the team. Findings may include multiple medical comorbidities, including recognized geriatric conditions (dementia, falls, functional impairment, failure to thrive) that are associated with high healthcare utilization.26 A comprehensive approach to the care of older adults with multiple comorbidities is key because these patients are at risk for receiving a great deal of healthcare interventions with questionable outcomes in terms of efficacy, satisfaction with care, and quality of life. This is the very population for which palliative care is most appropriate. The principles of geriatric care as described in the literature are listed in Box 15.1.27,28

From references 27 and 28.

These principles of geriatric care are synergistic with The Clinical Practice Guidelines for Quality Palliative Care developed by the National Consensus Project for Quality Palliative Care.2 These guidelines are the foundation for evidence-based practice in palliative care and, like the principles of geriatric care, are based on the belief that the most appropriate care is holistic and comprehensive and ensures that the patient and family are integral to care planning and decision making. The synergy extends to the prominence of the interdisciplinary team in addressing the complexities of care. Eight domains for palliative care are delineated within the guidelines and provide structure for the delivery of palliative care.

Optimal outcomes for the older adult in need of community- based palliative care can be achieved when the principles of geriatric care and the guidelines for quality palliative care are applied simultaneously to clinical practice. The resultant practice model addresses all the needs of the patient and family and takes into account the dynamic nature of acute and chronic illness as experienced by an older adult. The experiences of family and caregivers are also attended to within this framework; families figure prominently in the assessment of the patient and are understood to be full participants in the palliative care experience.

The intersection between the principles of geriatric care and the guidelines are multifaceted, with significant conceptual overlap. When considered as a conceptual whole, this integrated practice model for geriatric palliative care provides an alternative paradigm for the care of older adults in the community setting from the point of diagnosis of chronic illness to the end-of-life. Figures 15.1 and 15.2 illustrate the diverse ways two selected domains and the guidelines converge. A unique domain for palliative care is at the center of each figure. Branching out from these are the various geriatric principles, followed by examples of the application of each for practice.

Figure 15.1 Domain 2: Physical Aspects of Care

Figure 15.1 Domain 2: Physical Aspects of Care

Figure 15.2 Domain 3: Psychological and Psychiatric Aspects of Care

Figure 15.2 Domain 3: Psychological and Psychiatric Aspects of Care

Case Studies and Application of Principles and Domains

Case Study 1

Mr. W was a 90-year-old white male living at home with his wife. His diagnoses included coronary artery disease, hypertension, and early dementia. His medications included ASA 81 mg QD, lisinopril 10 mg QD, and Aricept 10 mg QD. His wife, a frail 88-year-old, had mild cognitive impairment but was able to manage their basic needs within the home. The couple needed assistance for some activities of daily living and relied on the support of 24-hour nurses’ aides. A home care nurse visited monthly to monitor medications and their overall condition. Mr. W had advance directives as well as a community DNR and a completed MOLST form that specifies comfort care only. Recently Mr. W was noted to have new-onset slurred speech and weakness on his left side. This prompted a call to the nurse by the aide. The nurse case manager visited and evaluated the patient using the FAST scale from the American Stroke Association, evaluating for facial droop, arm weakness, speech difficulties, and time of onset of symptoms.29 She verified a blood pressure of 150/94 and a regular pulse of 76.

The geriatric APRN was notified and the patient was given an extra dose of ASA 81 mg, as he was beyond the window of opportunity for treatment with tPA.30 The APRN reviewed the advance directives and consulted the physician and social worker at the geriatric clinic. After reviewing the options, she phoned the son, who was the healthcare proxy. The decision was made to bring the patient to the outpatient geriatric center the next day for care, as the son wanted him to have an evaluation that included a full workup for stroke. The son believed this action was most consistent with his father’s advance directives.

At the clinic, the APRN evaluated the patient’s status. The EKG showed no evidence of atrial fibrillation or acute changes from his previous EKG. His bloodwork included a PTT, PT, INR, CBC with platelet count, cardiac markers, electrolytes and renal function, lipid panel, and vital signs with oxygen saturation.30 His physical exam included complete neurological and functional evaluations and a geriatric mental health exam. The NIH screening tool was used to evaluate his stroke, and a bedside swallow evaluation tool was used as well.31 Mr. W was found to have an adequate swallow and was believed to be over 12 hours from the onset of symptoms. During this visit, the plan of care was discussed with the patient and son, including the option of radiologic testing. The decision was made to send him for a CAT scan of the head so an ischemic stroke could be confirmed.30

The following day the son returned to the clinic for a care planning meeting with the team. The plan included monitoring and management of blood pressure to maintain a BP of less than 140/90; an increased dose of ASA to 160 mg per day; and evaluation by PT, OT, and ST for safety at home and nutritional needs.32 They discussed adding a statin pending the results of the lab work and a discussion of the risk/benefits in light of the patient’s age. Since the patient’s advance directives expressed his wish to remain at home and avoid hospitalization, the son made clear that Mr. W would not be hospitalized even if his condition worsened. The son discussed concerns regarding the increased burden on his mother and shared that he would temporarily move in with them. The team agreed that a regular diet with thin liquids was appropriate as the patient showed no evidence of aspiration on evaluation. The APRN planned to educate the caregivers in the home on aspiration prevention using the Hartford Institute for Geriatric Nursing Preventing Aspiration Guideline.33 During the team meeting, the APRN offered the son a referral to a local Alzheimer’s disease caregiver support group.

To further ensure high-quality care with respect to the goals of care, the APRN visited the home, spoke with the aides, and provided education about the new plan of care. She emphasized the need to call the APRN or covering team in the event of a change in status and not 911. The plan was placed in writing in the home, next to the MOLST and DNR.

In general, response to this case can be guided by the following principles of geriatric care:

  • Care is interdisciplinary/multidisciplinary.

  • Medical conditions are chronic, with multiple comorbidities, and multifactorial.

  • Care is patient- and family-focused.

  • Understand who the primary decision maker will be.

  • Provide comprehensive assessment that considers physical state, emotional state, quality of life, well-being, sources of primary support, and optimal level of physical function.

Domain 1: Structure and Process of Care

Palliative care is based on comprehensive assessment of the patient; change in status drives reevaluation of care. The assessment and plan of care reflect the understanding and desires of the patient and family and are focused on promoting quality of life as they define it. The plan of care includes consideration of the physical environment to ensure safety and functional needs are met. Care is interdisciplinary and involves all members of the team, the patient, and the family. The APRN is responsible for reviewing these regularly with the patient and family, taking into account the patient’s cognitive ability to continue to participate in decision making.

Domain 2: Physical Aspects of Care

Pain and symptom management is a primary focus of palliative care. Assessment is evidence-based, documented, and performed by trained professionals. While Mr. W did not need active pain and symptom management, this was part of the ongoing assessment, as was evaluation of his neurological symptoms. Should Mr. W require pain management, appropriate administration and safe use in the home will be critical considerations in light of both his and his wife’s cognitive status. In the outpatient setting, pain is assessed at each visit with the primary provider. As Mr. W’s primary symptoms were neurological, it was appropriate to use the FAST and the NIH Stroke Scale in the clinic or at home (recommended by the American Stroke Association) for screening and response at recommended intervals.29

Domain 3: Psychological and Psychiatric Aspects of Care

In the presence of a change in cognitive and mental status, they are evaluated using developmentally appropriate tools. Care includes identification and recognition of loss, grief, and depression in patients and family. Differentiating between grief and depression is important because their definitions, clinical features, and interventions are different.34 Education and support are provided for patient, family, and staff. The use of a Geriatric Mental Status Exam with Mr. W on an ongoing basis provided for evidence-based practice and ensured that care was developmentally and cognitively appropriate.35

Domain 4: Social Aspects of Care

Continued change in status will require ongoing assessment and evaluation of needs. Additional assistance may be needed in the home to allow aging in place; this will prompt an evaluation of financial resources and a meeting with the patient and his wife and son to discuss the goals of care and options for achieving those goals. Advance care planning is reevaluated to ensure that remaining at home and avoiding hospitalization remain a priority. Services like home-based meal programs, social or medical model senior day care programs, and transportation services, as well as coordination of services through local government programs for the elderly, support the desire to remain in the community and avoid social isolation.

Case Study 2

Mrs. T was an 84-year-old woman who presented to her primary care provider with radicular pain radiating from her lower back down her right leg. She was independent in all activities and had an active social life in her community. Her primary support was her son and family, who lived up north. Her medical history was significant for hypercholesterolemia, for which she received Zocor 10 mg QD, osteoporosis treated with calcium supplements, and mild cognitive impairment treated with Aricept 10 mg QD. She declined treatment for depression.

Her radicular pain had developed 2 months earlier, resulting in limitations of physical activity. She was referred to a rheumatologist and L/S spine x-rays were negative, showing only degenerative changes consistent with age. Conservative management included PT and a series of cortisone injections. These proved to be ineffective. Reevaluation revealed L/S spine bony destructive changes consistent with metastatic disease. A bone scan revealed metastatic spread to the pelvis and right femur. Pathology results of the bone biopsy showed small cell carcinoma of the lung. A CT of the chest showed a right upper lobe mass. Palliative radiological treatment effectively reduced most of the radicular pain. Mrs. T was referred to a palliative APRN for symptom management. For relief of her nausea she was prescribed Zofran ODT 4 mg tablets q8h PRN. The patient had been placed on NSAIDs previously and was intolerant of these drugs due to gastrointestinal side effects. She had been taking acetaminophen PRN but with little relief. She was started on oxycodone 5 mg q6h as needed for pain.36 A safety plan was implemented by physical therapy that included home support and services with a move closer to her son. A new assessment offered a prognosis of 12 to 18 months with appropriate advance care planning. She agreed to a trial of palliative chemotherapy. With chemotherapy she experienced nausea, vomiting, loss of weight, change in cognition, and new onset of a DVT, with minimal response. She decided to discontinue therapy.

A new pain regimen was initiated and included OxyContin 10 mg q12h to promote comfort and function. A dose of 5 mg of oxycodone q4h was continued for breakthrough pain.36 The ondansetron ODT was continued for nausea as needed. A new plan included pain control, nutritional issues, mild exacerbation of her mild cognitive impairment, unresolved family issues, grief related to the recent cancer deaths of her husband and another son, safety issues, and coping. The APRN assessed Mrs. T’s nutritional risk using the Mini-Nutritional Assessment Short-Form (MNA®-SF).37 She was offered a referral to social work to address her depression and grief and spiritual support, both of which she declined. An evaluation of the home was conducted using the CDC Check for Safety Home Fall Prevention Checklist for Older Adults,38 and recommendations were made regarding assistive and adaptive devices.

Over the next 6 months, Mrs. T’s disease progressed with an increase in pain and continued weight loss. The patient and her family were instructed in the safe use of opioids. She developed SOB and a deep nonproductive cough along with lower limb swelling. She raised the question of a return to treatment as an option to cure her disease. While her family supported her decision to forgo treatment, she herself was unsure. The risks and benefits of treatment were addressed by the palliative APRN. Mrs. T declined further treatment and reaffirmed her desire to remain at home even in the face of increased severity of symptoms. To enhance her safety at home, Mrs. T agreed to an increase in the hours of an aide.

About 6 weeks prior to her death and a year after diagnosis, Mrs. T began to experience significant decline, including severe SOB, lower-extremity edema, increased pain in her back and hip, increased periods of fatigue and sleeping, loss of appetite, and weight loss. A review of medications was conducted by the APRN to eliminate unnecessary medications in light of her prognosis. The palliative APRN discussed goals of care with the primary care team, the patient, her son, and other family members. The patient found oxygen helpful but declined hospice. She died 6 weeks later with home health support.

Domain 1: Structure and Process of Care

The care for Mrs. T was interdisciplinary and coordinated and subsequent reevaluations were provided as needed. All aspects of her status were considered, including presenting symptoms, prior history, and response to past treatment. Prognosis and quality-of-life considerations weigh heavily in consideration of care planning. Goals are set by the patient and family, and Mrs. T was the primary decision maker until the end of her life.

Domain 2: Physical Aspects of Care

Symptoms may involve multiple systems, and specialist-level expertise is needed to achieve relief. Validated assessment tools are used to guide evidence-based practice. When opioids are prescribed, a risk/benefit assessment is conducted regularly, with appropriate patient and family education. Mrs. T’s pain and symptoms were managed conservatively with OxyContin 10 mg q12h based on her request that she remain cognizant.36 By “starting low and going slow” with increases in doses, Mrs. T had excellent pain management, without changes in cognition, including delirium. Medications that were not essential to managing her cancer and symptoms were discontinued (including Aricept) to reduce the possibility of toxicity.

Domain 3: Psychological and Psychiatric Aspects of Care

The palliative care team assesses and responds to the patient’s psychological distress. Mrs. T had a premorbid diagnosis of depression and was assessed as experiencing unresolved grief related to the death of her husband and son, her own diagnosis, and other complex family issues. She was offered support and treatment and declined them. There are several tools to assess depression that would have been appropriate for use, including the Geriatric Depression Scale.39 Despite her distress, Mrs. T was able to enjoy time spent with her family and friends and found great joy in her grandchildren. This love was reciprocated and she had the opportunity to meet the developmental task of aging, generativity, through these intergenerational relationships.

Domain 4: Social Aspects of Care

The goal of this domain is to support the patient and family in addressing broadly defined social needs. These include goals for care, grief, response to illness, communication, caregiving needs, and access to medication, equipment, and community resources. Mrs. T’s social concerns reflected her desire to stay connected with neighbors and family and remain active in the community. The palliative APRN ensured that Mrs. T had access to the services and assistance she required.

Domain 7: Care of the Patient at the End-of-Life

This domain recognizes the complex needs of the patient and family at the end-of-life. Education and support is provided to the family and other caregivers about the dying process. In anticipation of the dying process, the palliative APRN worked with the family and hospice to ensure that all appropriate medications were in the home and that family members who would be in attendance at the end-of-life knew how to administer them. The palliative APRN continued communication and care coordination to Mrs. T’s last days.

Case Study 3

Mrs. P was an 82-year-old female with a two-day history of SOB and swelling of the lower extremities. One week prior, she was seen by her primary care nurse practitioner for worsening SOB and was diagnosed with heart failure. Because of a history of renal failure, her diuretic dose was increased, with only short-term relief. She returned to the geriatric clinic for worsening symptoms.

Her past medical history was significant for type 2 DM, stage IV chronic kidney disease, and kidney cancer. Her chronic kidney disease was nearing stage 5, with a GFR of 15 mL/min. She was status post left nephrectomy and adrenalectomy. Prior conversations had included the possibility of hemodialysis in the future. A recent CT of the chest and abdomen showed no evidence of metastatic disease or cancer. Mrs. P lived independently in the community and relied on her daughter for support for healthcare provider visits. Though she described herself as “slowing down,” she stated her quality of life was satisfactory and described herself as healthy. She had decision-making capacity, though she included her daughter in all discussions.

Mrs. P had a history of CAD, for which she had undergone stenting twice, and a history of CHF and an EF of 40. She was involved in an outpatient CHF program and was well educated about her disease. Due to weight gain and increased swelling in her lower extremities and abdomen, she sought further care. The APRN’s assessment determined probable recurrence of CHF. Mrs. P’s medications were reviewed; she was on Lopressor 12.5 mg BID, irbesartan 150 mg QD, as well as bumetanide 0.5 mg QD40 (Table 15.1).

Table 15.1 Adverse Effects of Using Diuretics for Chronic Kidney Disease

Condition

Hypotension

Most common when initiating therapy or increasing diuretic use

Decrease in the glomerular filtration rate (GFR)

Most common with concurrent use of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors

Electrolyte abnormalities

Hypokalemia

Occurs with loop diuretics, sodium intake dependent

Hypomagnesemia

Hyponatremia

Hyperkalemia

Occurs with loop and thiazide diuretics

Hypocalcemia

Occurs with thiazide diuretics

Hypercalcemia

Occurs with loop diuretics

The APRN reviewed the patient’s advance care planning documents. Though her out-of-hospital medical orders for life-sustaining treatment (POLST/MOLST) stated she did not want hemodialysis, the patient and her daughter said they would like to discuss whether this was an option to stabilize her condition and increase her comfort. Though dialysis would not reverse her kidney disease, and despite the burdens, both Mrs. P and her daughter decided to proceed with hemodialysis.

The APRN was able to do bloodwork while the patient was in the office and obtain a chest x-ray, which revealed CHF. The APRN called the cardiologist and renal physician to coordinate a plan of care and discussed with Mrs. P what would happen next. She was prescribed oral bumetanide 1 mg BID as she was still making urine and there could be some response to the new diuretic dosing.41,42 Side effects of the medication were discussed with the patient and her daughter, as well as a plan to monitor electrolytes, renal function, and urine output. Mrs. P. needed a fistula; the primary care nurse practitioner discussed this with the renal physician, who thought it would be prudent to have access for possible dialysis earlier than a fistula would be available. The renal physician would work toward having a dialysis slot for Mrs. P. The APRN coordinated a visit with the renal physician in his office, as well as with the cardiologist.

The daughter was concerned about her mother’s increased weakness and believed she could not safely return home. The palliative APRN called visiting nurses to set up services to monitor Mrs. P at her daughter’s home. Mrs. P was reluctant at first to leave her own home but believed this would be temporary until she improved. The out-of-hospital medical orders for life-sustaining treatment (POLST/MOLST) were changed to reflect the new plan of care. The patient had a home visit from the palliative APRN as well as the visiting nurse, who was able to see that Mrs. P was responding to the increase in her diuretics. The APRN repeated her bloodwork due to the change in medication. She reviewed whether Mrs. P had any symptoms of postural hypotension. The diuretic medication was adjusted based on her response to the dose and in discussion with the cardiologist and renal physician. Once Mrs. P’s condition had stabilized, the APRN provided some anticipatory guidance with the patient and the daughter regarding the next steps in her care and the management of her chronic disease. The patient was seen by a vascular surgeon in order to have a central line and a fistula placed after her acute phase had resolved. If the patient had developed increased SOB, confusion, or nausea and vomiting due to uremia41,43 (Table 15.2), the plan would have changed based on her medical status, up to and including hospitalization. Referral was made to the nurse educator at the local dialysis center to prepare and educate the patient and her daughter regarding dialysis. Both patient and daughter stated that the goals of care remained symptom management and optimal quality of life in light of the new treatment. The plan of care was reviewed; additional education and anticipatory planning were provided for support and care in light of this change in status and the potential increase in care needs.

Table 15.2 Symptoms of Uremia in the Patient with Chronic Kidney Disease: When Dialysis Should Be Initiated and GFR Is <15 mL/min

Nutritional deterioration, including fatigue, anorexia, and weight loss

Excessive thirst

Visual disturbance

Muscle cramps

Pruritus

Mental status changes

Metabolic abnormalities, such as anemia or acidemia and electrolyte abnormalities, may be present

Poorly controlled cardiovascular problems can precipitate symptoms of uremia

Adapted from Medscape (2013) and reference 43.

Domain 1: Structure and Processes of Care

A primary criterion for this domain is that care is interdisciplinary and coordinated and reflects comprehensive assessment. Patient and family understanding of the illness, expectations of treatment, and goals of care are assessed. Quality of life is a prime consideration throughout. When developed, the plan of care is based on comprehensive assessment and in collaboration with the patient and family. With any change in condition, the priorities for care are reevaluated. In light of Mrs. P’s prior cancer diagnosis and the presence of complex chronic conditions, comprehensive assessment was integral to developing an appropriate patient-centered plan of care. Though 82 years old and with a significant medical history, this patient enjoyed an active life and perceived herself to be healthy. Her decision to address her shifting renal function with dialysis was made within the context of understanding that this was a palliative measure and would not “cure” her renal disease. The primary care nurse practitioner took a palliative care approach and coordinated communication and care across all healthcare providers. Communication was intentional and regular, resulting in a plan of care that reflected patient decision making with input from the family.

Domain 2: Physical Aspects of Care

The goal of this domain is safe and timely management of physical symptoms over time. Patient and family understanding of the illness and possible interventions is assessed and education is provided. In this care, the primary care nurse practitioner provided timely and appropriate physical care in response to the patient’s change in status. This was done from the perspective of managing her comorbidities and the goal of palliative intervention. Through a process of enhanced communication with all providers and coordination of care, the nurse enhanced the likelihood that care would support the patient’s goal for care. The recognition that Mrs. P had the capacity to remain independent was key to providing appropriate palliative interventions; the disease was addressed, but within the context of her larger life. Providing education about the course of treatment is a way to support the patient’s quality of life and need for ongoing management of her illness and symptoms for a disease that cannot be cured, the hallmark of good geriatric nursing and palliative nursing in the outpatient setting.

Domain 8: Ethical and Legal Aspects of Care

Ethical and legal aspects of care are addressed though an assessment of the patient’s and family’s choices for care. There is a defined process for eliciting values, care preferences, religious beliefs, and cultural considerations that is sensitive to the needs of the patient and family, and this should be revisited over time. Appropriate documents are completed to meet legal standards for implementation. As Mrs. P’s disease progressed, her decisions regarding palliative treatment with hemodialysis changed. In this case the APRN recognized that care decisions are dynamic and provided the patient and her daughter the opportunity to reevaluate prior decisions and update legal documents. The APRN is ethically obligated to do this and to ensure patient autonomy as well as meet the ethical principles of beneficence and nonmaleficence.

Conclusion

The increase in the total number of older Americans has resulted in an aging population that is living longer and will experience multiple chronic illnesses along with physical and functional impairment prior to the end-of-life.11 The implication of this is the need for increased access to a model of palliative care that is designed to meet the unique needs of an older population. APRNs will be essential to meeting the palliative healthcare needs of this population across the continuum of care and are poised to provide cost-effective and high-quality care for the frail elderly. While more research is needed to fully understand the parameters and specifics of what is needed in geriatric palliative care,44,45 the evidence currently available suggests that the APRN has a crucial role. Resources are available to the APRN to enhance knowledge and skills and support practice in this area. The Clinical Practice Guidelines for Quality Palliative Care2 is an essential document for APRNs working in this realm, as are the “Guiding Principles for the Care of Older Adults with Multimorbidity.”27,28 Other resources include clinical tools from the Center to Advance Palliative Care,46 the Try This series from the Hartford Institute for Geriatric Nursing,47 and the Fast Facts series from the Center to Advance Palliative Care.48

References

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