Recommendations to Leverage the Palliative Nursing Role During COVID-19 and Future Public Health Crises

William E. Rosa, PhD, MBE, ACHPN, FAANP, FAAN; Tamryn F. Gray, PhD, RN; Kimberly Chow, RN, ANP-BC, ACHPN; Patricia M. Davidson, PhD, RN, FAAN; J. Nicholas Dionne-Odom, PhD, MSN, MA, ACHPN, FPCN; Viola Karanja, BSN, RN; Judy Khanyola, MSc, RCHN; Julius D. N. Kpoeh, ASN, RN; Joseph Lusaka, BSc HM, DCM, PA; Samuel T. Matula, PhD, RN, PCNS-BC; Polly Mazanec, PhD, AOCN, ACHPN, FPCN, FAAN; Patricia J. Moreland, PhD, CPNP, FAAN; Shila Pandey, MSN, AGPCNP-BC, ACHPN; Amisha Parekh de Campos, PhD, MPH, CHPN; Salimah H. Meghani, PhD, MBE, RN, FAAN

Disclosures

Journal of Hospice and Palliative Nursing. 2020;22(4):260-269. 

In This Article

Recommendations for Optimizing the Palliative Nursing Role Now

Based on the need for palliative care during previous humanitarian emergencies, there are several evidence-based recommendations that can be extrapolated to the COVID-19 response, particularly in resource-constrained settings. These include concerted attention to palliative care throughout organizational policies and humanitarian responses at local and international levels; "just-in-time" training of primary teams and health care responders; training of community-based palliative providers to ensure timely and ongoing surveillance, counseling, and spiritual/psychosocial support; reliable referral systems and pathways to specialist palliative care consultation when possible; access to necessary medications and local system infrastructure to support storage, distribution, provision, and so on; and readily available palliative care beds in hospitals and clinics wherever feasible.[30] Palliative care—now more than ever—should be integrated into mainstream health care delivery and further upstream in the illness process to ensure all frontline providers have a degree of comfort managing symptoms, communicating empathically, and guiding important care discussions in a time of high stress and uncertainty. In circumstances where individuals have a preexisting life-limiting illness, such as heart disease, cancer, or chronic obstructive pulmonary disease, this is of critical importance.

Palliative nurses should leverage their local and global influence and leadership to ensure universal palliative care access during COVID-19 and beyond. Rosa and colleagues[31] recommended 4 primary ways nurses can play advocacy roles to advance this ideal (Table 1). Promoting nurse leadership in palliative care delivery is in alignment with current major global health agendas seeking to advance health equity and inclusivity and improve person-centered care mechanisms worldwide.[32–34]

Expanding the Palliative Nurse Role

Palliative nurses—as well as clinical nurses across specialties—need to be engaged as fully autonomous and contributory members of the interdisciplinary team. Supporting nurses' autonomy and independence as clinicians requires (1) organizations to ensure policies that promote them working to the full extent of their license; (2) multidisciplinary team members who understand and value the role and contributions of nurses; (3) healthy team dynamics that promote task sharing, shifting, and frequent rotation of leadership responsibilities; and (4) palliative nurse involvement in system and organizational decision-making for policy and protocol advancement.

The palliative nurse role should be expanded in accordance with both patient needs and palliative nurse capacity, for example, ensuring clinical nurse prescribing privileges to promote effective relief of symptomatic distress.[20] In many low- and middle-income countries (LMICs), nurses are already performing these roles without recognition or supervision. Additional examples of such privileges may include activating protocols established by health care organizations to treat pain, dyspnea, constipation, and delirium.[35] Empowering nurses to lead patient rounds and initiate team debriefings is likely to both improve team morale and increase transparency to efficiently identify patient needs during COVID-19.

Pain and Symptom Management

Effective pain and symptom management during COVID-19 is imperative. One of the most important roles palliative nurses will play in this pandemic is addressing the multidimensional suffering patients and their families will experience at the intersection of physical symptoms, emotional distress, and social isolation. Although some organizations have hurriedly developed basic guidelines for managing crisis symptoms associated with this disease, there are no widely accepted guidelines for chronic pain or complex symptom management amid COVID-19. However, international initiatives are collating expert opinion to provide recommendations focused on continuity of care and access to analgesics and opioids for those in need of moderate to severe pain relief, optimizing telehealth access, concomitant use of steroids and anti-inflammatory medications as appropriate, prioritizing procedural and multimodal interventions as available, ensuring safe triage, promoting effective patient flow and staffing, and implementing risk mitigation strategies.[36,37]

Given the pulmonary, gastrointestinal, neurocognitive, and other symptoms that evolve quickly in the setting of COVID-19, patients' distress must be attended to promptly. Considering which patients may be at higher risk of baseline symptom exacerbation in the context of COVID-19 is essential. For example, the majority of patients with cancer are likely to experience pain as one of the most negative symptoms throughout their disease trajectory and into survivorship.[38–40] Pain management becomes a crucial priority in such populations who may also confront symptomatic flares while receiving active treatment, such as chemotherapy or radiotherapy. The experience of COVID-19 may further escalate subjective pain and other symptoms. In addition, understanding what symptoms can be managed remotely versus those that need immediate and potentially lifesaving attention is critical.

Symptom severity at end of life is heightened for those suffering from COVID-19, often requiring high-dose analgesic and sedative regimens. Palliative nurses should be partnering with clinical nurses and interdisciplinary teams to support primary palliative care, particularly in the realm of assessment and treatment and in the context of each patient's individual care goals.

Advance Care Planning

Palliative nurses can play a vital role in promoting early completion of advance care planning (ACP) during the COVID-19 pandemic. Given the multiple populations at higher risk of COVID-19 complications, including older persons, the immunocompromised, and those with multimorbidity, ACP conversations are needed as early as possible in the care trajectory. During the week of March 15, 2020, more than 4000 requests for the advance directive tool, "Five Wishes," were tracked, a 10-fold increase from baseline.[41] ("Five Wishes" is now being offered free of charge to individuals online during COVID-19 at https://fivewishes.org/five-wishes-covid-19).

Palliative nurses should be leading goals-of-care communication, eliciting patient understanding about risk and intervention options given a diagnosis of COVID-19, and helping to identify the values and priorities of individuals, families, and communities. Such discussions are likely to encompass decisions around ventilation, pressor support, intensive care unit escalation, and patient readiness for hospice. Given that nurses spend substantively more time with patients than other professions and have consistently been noted as the most trusted profession, they likely possess relational insights with patients and family caregivers that can lead to timely and informed ACP decision-making in a timely manner to reduce unnecessary hospital admissions and increase access to transitional care needs.

Palliative nurses are also influential in encouraging families as early as possible to have difficult but necessary conversations with loved ones about their wishes for care if they become critically ill.[42] Additionally, given resource constraints, widespread do-not-resuscitate orders for COVID-19–positive patients who meet certain clinical criteria, and a potential spike in rationing practices, palliative nurses need to feel comfortable guiding ethical discussions and helping to resolve clinical disagreements. These clinicians should be partnering with ethics committees as well as primary teams to anticipate ethical challenges, encourage open communication for patient and family members to express worries and concerns, and ensure potential moral distress of partner colleagues is identified and addressed in a supportive manner.

Communication and Whole-person Care

During the current COVID-19 era, many hospitals and other health facilities are restricting visitors to inpatient units, and there have been a number of media reports of patients dying alone. Palliative nurses should work closely with inpatient and community-based primary and palliative care team members to ensure continuous dialogue with family members, ensuring timely updates about the patient's clinical condition and assessing how they, as caregivers, are coping with separation and grief. Doing so will help build trust, open channels of communication, potentially minimize caregiver distress, and assist with anticipatory grief and bereavement.

The use of technology (eg, smart pads and other institution-specific platforms) should be encouraged to address patient isolation, improve communication with family and the interdisciplinary team, and improve assessment of personal or disease-related needs. Spiritual, religious, and other end-of-life care needs should be elicited upon consultation for the COVID-19–positive patient to ensure proactive person-centered care, even when the physical presence of the palliative nurse at the time of death may not be feasible. Additionally, facilities heavily impacted by COVID-19, such as long-term care, skilled nursing, and assisted living, would benefit from palliative nursing input to mitigate patient distress and assist in supporting staff members with coping strategies.

Advanced Practice Palliative Nurses

The expanded roles of advanced practice registered nurses (APRNs) must be supported at institutional, local, national, and international levels where applicable. Consistently, on the policy and legislative front, there are urgent calls for supporting a robust and interdisciplinary workforce to be responsive to the needs of the volume of serious illness patients. For example, the Coalition to Transform Advanced Care sent a letter to congressional leaders on March 18 of this year to authorize nurse practitioners to be able to provide the initial certification of patients for hospice care, in addition to their current abilities to recertify patients and serve as attending providers.[43]

In addition, several state governments in the United States have suspended mandatory collaborative practice agreements to promote full practice authority and increase prescriptive authority for nurse practitioners. The Drug Enforcement Agency has also permitted the prescription of scheduled medications with telemedicine consultations.[44] These policy changes elevate the nursing contribution, alleviate palliative care team stress by promoting task shifting and advanced practice nurse autonomy, and increase workload sharing and flexibility for health care and palliative care teams.

The independent practices of palliative nurse practitioners and other APRNs (eg, clinical nurse specialists) must continue to be supported by institutions, collaborating interdisciplinary colleagues, and local and national policy stakeholders. Palliative APRNs should be leveraging telehealth approaches both inpatient and in the community and educating themselves about billing changes, flexibilities, and waivers from Medicare, Medicaid, and other commercial carriers during this public health emergency.[45–47] COVID-19 becomes an opportunity for APRNs to role model practice expertise and further demonstrate their long-standing excellence in patient outcomes amid the pandemic as an argument for continued full practice authority across a number of fields and in the future. Such scope of practice expansions should be sustained after the COVID-19 crisis to avoid piecemeal reforms during emergencies.

Collaboration With Hospice

Overburdened acute care settings should be leveraging the services of hospices as much as possible throughout the COVID-19 pandemic. Hospice nurses serve as extremely valuable resources of clinical knowledge and may support in-hospital palliative care and primary teams with necessary transitional and hospice qualification information. Nurses working in hospice may also be able to assist with community-based telemonitoring of the seriously ill who are symptomatic with COVID-19 and can offer additional psychosocial support to families and caregivers in bereavement. However, optimizing the contribution of hospice nurses will require rapid policy changes to ensure reimbursement for the full extent of services hospices should be able to provide during COVID-19.

Global Nursing Partnerships

Lastly, palliative nurses should seek to promote partnership and mutual learning among nurses in different countries.[31,34] Low- and middle-income country health care workers are managing ever-increasing aging populations coupled with an expanding number of chronic conditions such as diabetes, heart disease, and kidney failure.[48] The associated care concerns and financial implications are affecting quality of life for these individuals and their families, communities, and overly strained governments. In LMICs, infectious diseases such as HIV/AIDS and malaria are draining existing resources.[48] Thus, partnering across countries will assist in the creation of new knowledge, accelerate translation from research to practice, and continue to establish the evidence-based value of palliative care on a global scale.[32–34]

There are a number of lessons to be learned from nurses in LMICs and their experiences during previous health disasters, which can be used immediately in the COVID-19 palliative nursing context worldwide. For instance, nurses working in the Ebola viral hemorrhagic fever outbreak in West Africa between 2014 and 2015 identified personal and professional needs prior to, during, and after deployment with the intent to improve future health emergency responses.[49] Although these nurses were faced with cross-cultural and global health issues during their assignments, the findings maintain relevance in the COVID-19 acute care and community-based settings and are focused mostly on improved education, communication, teamwork, and mental health support. Based on the experiences of nurses working with Ebola patients,[49] consider the following, adapted to the current context:

  • Prior to delivering care in the COVID-19 environment (particularly for new or student nurses currently transitioning to practice): palliative nurses should seek additional training related to leading goals of care and ethical discussions as needed; gain knowledge of institutional resources to educate patients/families on escalation interventions available (eg, intensive care unit–level care); and stay informed about empirical evidence related to likely outcomes for patients with serious illness or other high-risk factors who test positive for COVID-19.

  • During the COVID-19 response: need for collaborative engagement of palliative nurses across communication, symptom management, and ethical domains; call for respect of all team member contributions and skills; flexible workload, responsibility, and task shifting for all team members; frequent opportunities for debriefing.

  • Following the COVID-19 pandemic: ongoing mental health support, individual and team debriefing, and self-care, coping, and resiliency skills to equip palliative nurses for future outbreaks and process their COVID-19experience.

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