Advanced Practice Nursing Roles

A Palliative Care Nurse Practitioner

Bonnie Freeman, DNP

Disclosures

August 17, 2017

Discovering a New Field

Bonnie Freeman, DNP, ANP-BC. Courtesy of Bonnie Freeman.

I was a palliative care nurse long before the discipline was formally identified. I always went out of my way to keep my patients' pain under control and their symptoms effectively addressed. In my role as a patient advocate, I tried to keep patients and families actively involved in care decisions. I could talk comfortably about a patient's code status and knew the importance of being compassionate. In 2007, I heard about a program called the End-of-Life Nursing Education Consortium (ELNEC) and a new medical discipline called palliative care. I finally found my true home.

My training for a job in palliative care evolved after attending ELNEC. I wanted to learn more, so I studied for and passed the certification exam for hospice and palliative care nursing , and I did my master's thesis on "Barriers to Providing Palliative Care in an ICU Setting." My research findings made me acutely aware of the education deficit that existed for many nurses when caring for the terminally ill and dying. Four months after obtaining my MSN degree, I enrolled in an adult nurse practitioner post-master's certificate program with a focus in palliative care through Vanderbilt University in Nashville, Tennessee. I accepted an inpatient hospice nurse practitioner (NP) position at the San Diego Hospice and Institute for Palliative Medicine, where I had the opportunity to attend daily lectures and workshops and learn from the leading experts in palliative care. I was deeply influenced by this experience and continue to work to maintain the standards of care set by this program.

What Does a Palliative Care NP Do?

My typical day involves the assessment and care of patients assigned to me by physicians in my group. The consult and plan of care are initiated by a physician, and I provide the follow-up management in an outpatient clinic, inpatient hospital setting, or by triaging over the phone. Often my care is focused on pain management, but I address other issues such as nausea, constipation, depression, and establishing goals of care. I initiate any necessary consults and request involvement from my palliative care team members to provide whatever support is needed.

My preferred focus within palliative care is to work with the terminally ill and dying. I provide emotional support for patients, families, and staff, and act as a patient and family advocate for their wishes. I initiate comfort care orders based on the CARES (comfort, airway, restlessness and delirium, emotional and spiritual support, and self-care) tool, a resource I developed as part of my DNP research requirements. It addresses the five most common symptom management needs of the dying and was adopted housewide at my facility. I also found that I needed to spend time with the nursing staff because they are emotionally affected when caring for the dying, so I try to be a supportive presence for them, too.

A Different Kind of Expertise

What I like about being a nurse is the ability to make a difference in the lives of patients and families, whether it is through providing bedside care or developing educational tools.

There were no palliative care programs for NPs when I started, so I obtained certifications and placed myself in environments with individuals doing what I wanted to do. I found that if you are truly passionate about something, you will find a way to achieve it. I am grateful for the guidance and support I was able to obtain here at City of Hope.

Taking the time to truly listen, empathize, and be compassionate are tools that should be valued as much as any other clinical expertise.

Bonnie (right) and John, one of her outpatients. Bonnie has been seeing John for 6 years to help manage chronic side effects from leukemia treatment. Courtesy of Bonnie Freeman.

Challenges and barriers to becoming a palliative care NP center around a culture that views death as a failure, and physicians and administrators who don't feel that there is a need for palliative care services. These barriers cause me to work even harder to show the difference I can make in a patient's care. Taking the time to truly listen, empathize, and be compassionate are tools that should be valued as much as any other clinical expertise. Thankfully, the climate is slowly changing, and with education, time, and patience, I hope to help make palliative care a standard resource for all patients (Figure 2).

Bonnie is in the process of making an independent film called Resilient Hearts, focusing on the humor and compassion used by a palliative care team trained to help celebrate life during the dying process. If you would like to find out more, visit www.resilientheartsproject.com and read Bonnie's blog.

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