The Role of the APN in Symptom Management
The Scope and Standards for Hospice and Palliative Nursing Practice (2002) state: "Because of their proximity to patients, APNs are in ideal positions to assess, diagnose, and treat pain and other symptoms." Given the advanced clinical knowledge and experience of the APN, providing quality symptom management is easily within the practitioner's purview. In order to offer care from a palliative perspective, there are some general principles that the clinician should bear in mind when treating the patient and caring for the patient's family.[3,13,14]
First, discuss the goals of care and treatment options with the patient and family. This should be an ongoing discussion, as decisions and wishes that are appropriate at one point might not apply a few months later. An individualized plan should be created in collaboration with other team members, taking into consideration the patient's general condition, the presence and severity of symptoms, the expected survival, and the preferred place of care.
The APN may be the most appropriate team member to guide discussions about advance directives. According to Dahlin, advance care planning is "a process of initiating discussion, reflection and understanding of one's health state in terms of goals, values and preferences for future treatment, including decision making around life sustaining treatments. The process begins with the patient's understanding of the disease and discussion related to possible medical scenarios, leading up to death."
These discussions should begin as early in the relationship as possible, before the patient and family are in the midst of crisis. This allows them to come to terms with difficult choices at their own pace, not because of a medical emergency. By discussing some of the burdens and benefits related to life-sustaining treatments, the APN can empower the patient and family to make informed decisions, possibly even giving them a sense of control at a time when everything can feel out of control. These conversations will foster a sense of trust between the patient, the family, and the APN. Once wishes are known, the APN can then advocate for the patient and assure the communication of those wishes to the relevant caregivers and healthcare providers.
Second, treat the underlying cause of a symptom whenever possible and be consistent with the goals of care. For example, if treating a respiratory infection with antibiotics will facilitate management of dyspnea and if the patient and the family are in agreement, this intervention should be one of the first implemented. If, however, the patient has already received multiple courses of antibiotics without improvement, this therapy may be futile and would not be in the patient's best interest.
Third, avoid new problems when intervening. Be sensitive to the possibility of side effects or the complex burden of an intervention, be it physical, psychological, social, or even financial.
Fourth, consider whether a treatment will be worthwhile. For example, a nephrologist might recommend that a patient receive outpatient hemodialysis, which might have only a slight life-extending promise, without discussing or considering the logistics of getting the patient to and from treatments.
Finally, anticipate and prepare family and caregivers. Prevent rather than react to crises. For example, educate families and caregivers about potential medication side effects, complications, or emergencies. Provide concrete interventions that the caregivers might implement to manage these situations.
Topics in Advanced Practice Nursing eJournal. 2006;6(4) © 2006 Medscape
Cite this: The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea - Medscape - Dec 31, 2006.