Mrs W had her provider document that she desired her daughter to be her health care proxy if she became unable to make decisions about her care.

At this patient’s practice, the primary care palliative team members were certified and experienced in providing palliative services. They completed continuing education on an ongoing basis and educated staff regularly. A primary care practice goal of theirs was to support palliative and EOL dialogue and to become actively involved in patients’ advanced care planning. The practice worked collaboratively with the front office staff, providers, and technicians and nurses to systematize and integrate this approach with all the patients. Palliative care resources and specialized community palliative teams were consulted for more challenging patients. 


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A palliative care checklist 

Incorporating good communication skills in delivering tough news, describing palliative care, setting patient goals, and involving caregivers are essential for patient-centered care.17,18,24 Patients need to understand the expected trajectory of their serious illness and the types of advanced care planning that should be considered. The SPIKES (setting, perception, invitation or information, knowledge, empathy, summarize or strategize) acronym25 is a helpful tool for providers delivering bad news early in the course of a life-threatening illness. Primary care providers should have discussions about ADs no later than at the time of the first diagnosis of a serious illness. Alternatively, standard visits can be considered beginning at age 65 years, and many suggest having discussions with primary care patients earlier.4,8,17,18,26 Besides ADs, in various scenarios, a surrogate decision maker and out-of-hospital orders for life-sustaining treatment should be included for comprehensive information. 

A checklist for incorporating a palliative approach into a primary care practice appears in Table 3. It is derived from the IOM report2 as well as current studies examining palliative care in primary practice.4,14,17,23 Besides best practices to initiate primary and follow-up appointments with patients, the checklist emphasizes the need to consider ADs with clinical decision making, and it reinforces the need for communication and collaboration with SNF coordinators, specialists, hospitalists, and EDs.14 In addition, the checklist includes an ongoing assessment of a practice’s palliative care outcome measures, such as completed consultations and patient and family satisfaction surveys.

The best resources for information on palliative care to be used in primary care practice are listed in Table 4. Table 5 lists websites for patients. These are especially relevant for primary care providers who are building palliative care processes aimed at helping patients develop evidence-based EOL ADs. 

Conclusions and future recommendations

All primary care providers (not just those treating patients with chronic illnesses or the dying) are responsible for teaching their patients about palliative care. Providers should have quality EOL discussions with their patients in a timely and ongoing manner. Doing so affords patients the necessary information, consistent good-quality management, and (when required) transitions in care (eg, transfer to hospice services). The earlier the introduction to the palliative care approach, the better. 

The palliative process requires standardization and a “kick start,” particularly in primary care practices and clinics. Developing a palliative care team and incorporating EOL visits into a primary care practice provide a solid beginning. Demonstrated competency (eg, continuing education units) and/or certification in discussing ADs is certainly important and will undoubtedly become required for providers. EOL care should become part of standard medical, nursing, physician assistant, and nurse practitioner curricula,4,19,24 so that providers become comfortable and more seasoned in providing information and ongoing management. 

Advanced care planning has been shown to improve patient and family satisfaction and allow care that is evidence-based, with fewer hospitalizations.2 It is essential that primary care providers address the many unmet needs of patients and families during the patients’ later years.

By initiating the palliative care dialogue, the primary care team can identify specific needs and goals, manage symptoms, coordinate care, and determine when additional resources are necessary. When incorporating EOL care into primary care, providers need to consider the process as “the beginning of a journey,” with treatment geared to provide the highest quality of life possible for the longest possible time. An interdisciplinary approach will provide a holistic focus and address comprehensive care for patients and families.18,27 Primary care providers have tremendous potential for ensuring access to and delivery of palliative care by reaching patients with all life-threatening illnesses, meeting their needs across all domains (physical, spiritual, social, and emotional), and providing care and support in a variety of primary care settings. Let the journey begin. 

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Joanne Stevens, PhD, FNP-BC, ARNP, is an associate professor of nursing, Megan Flanagan, FNP-BC, ARNP, is an alumna, and Tressa Pedroff, MSN, RN, is a clinical instructor at University of Tampa in Florida. Megan Flanagan, FNP-BC, ARNP, practices at Lifetime Obstetrics and Gynecology in Tampa. 

References

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