1. Module 1: Introduction to Palliative Nursing Care

2. Key Learning Objectives
At the completion of this module, the participant will be able to:
Describe the role of the nurse in providing quality palliative care for Veterans.
Identify the need for collaboration with interdisciplinary team members while implementing the nursing role in palliative care.
Recognize the unique demographics, health care economics, and service delivery for Veterans that necessitates improved professional preparation in palliative care.
Describe the philosophy and principles of palliative care and hospice palliative care that can be integrated across settings to affect quality care at the end of life for all patients.
Discuss aspects of assessing physiological, psychological, spiritual, and social domains of Veterans and families facing a life-threatening illness or event.
Explain various resources available to Veterans and their families.

3. Department of Veterans Affairs Motto
“…to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”
President Abraham Lincoln
2nd Inaugural Address

4. “To honor Veterans’ preferences for care at end of life.”
Department of Veterans Affairs Hospice and Palliative Care Program’s Mission
“To honor Veterans’ preferences for care at end of life.”
VHA, 2008b, p.1

5. Demographics of Veterans
Projected
Total U.S. Veterans population: 21,681,000
Women Veterans population: 2,035,213
Surviving WWII Veterans: 697,806
Enrolled Veterans are older adults; multiple comorbidities
Homeless Veterans
VA, 2015a; National Alliance to End Homelessness, 2015

6. Characteristics of the Veterans Health Administration (VHA)
The largest integrated healthcare system in the U.S.
Many layers and program services
Nurses care for Veterans in VA and non-VA community settings
Casarett et al., 2008a & 2008b; NHPCO, 2011

7. Facts about Veteran Deaths and Palliative Care in the VA
Less than 4% of Veterans die in VA facilities (NHPCO, n.d.a)
1 out of 4 dying Americans is a Veteran (NHPCO, n.d.b)
WWII Veterans: 430 dying each day (National WWII Museum, 2016)
19,000 inpatient deaths per year in VA hospitals and Community Living Centers

8. Facts about Veteran Deaths and Palliative Care in the VA (continued)
40,000 palliative care consults per year
8,000 receive home hospice via contracts (VHA, 2008)
Palliative Care Consult Teams at each VAMC (n=139)
Hospice-Veteran Partnerships (NHPCO, n.d.a)

9. Exercise – Stop and Consider:
Download and watch video at:

10. Nurses Caring for Veterans Must Understand Their Unique Culture
Enrolled Veterans: at-risk for unemployment, poverty and homelessness (JEC, 2015)
Many live in rural settings (NHPCO, 2011 & 2014b)
Military camaraderie and respect
Culture of stoicism (Grassman, 2015)

11. Differences in Cause of Chronic Illness and Death by Wars
World War II
Korean War
Vietnam
Gulf War
Operation Enduring Freedom/Operation Iraqi Freedom-now Operation New Dawn
VA Veterans Health Concerns

12. Various Experiences Can Affect a Veteran’s Dying
What branch of service?
Enlisted? Drafted? Rank?
Age?
Combat and/or POW experience?
PTSD (assess for social isolation, alcohol abuse, anxieties)?
Stoicism
NHPCO, n.d.b & n.d.c.

13. Dying Concerns and Preferences of Americans
Fears
Preferences
Family Considerations
Military Experience

14. Barriers to Quality Care at End of Life
Failure to acknowledge limits of medicine
Lack of training
Hospice/palliative care misunderstood
Rules and regulations
Death-denying society
U.S. Grade of “B” in palliative care
CAPC, 2015, Coyle, 2015

15. Hospice and Palliative Care
Ideally begins at the time of diagnosis
Can be used to complement medical treatments
Occurs across all settings
Hospice:
Most intense form of palliative care
Prognosis: < 6 months to live
Patient agrees to enroll in hospice and chooses not to receive non-beneficial care
NCP, 2013

16. Both Hospice and Palliative Care
Interdisciplinary care
Pain and symptom management
Physical, psychological, social and spiritual care
Role of the nurse: empathy, unconditional positive regard, genuineness, attention to detail (Berry & Griffie, 2015)

17. Hospice Care in America 2014
6,100 hospice programs
1.6 to 1.7m patients received hospice care
Ethnicity: 92.9% Non-Hispanic/Latino origin
Location of hospice patients at death: 58.9% in patient’s place of residence, 31.8% hospice inpatient, 9.3% acute care
Age: 83.9% of patients age 65 and older
Days on hospice care: median 17.4 days, mean 71.3
Diagnosis: 36.6% cancer, 63.4%, non cancer
NHPCO, 2015

18. Eligibility for VA Hospice Benefit
Included in the Medical Benefits Package (both inpatient or home settings)
Eligible for both VA and Medicare may elect to have hospice paid for by either benefit
VHA, 2005

19. Hospice Care for Veterans
Hospice care provided at home
Inpatient care provided (VHA, 2005)
VA contracts with Community Nursing Homes (CNH)
VA may purchase inpatient hospice care from a community provider
Concurrent palliative and hospice care among Veterans with cancer beneficial (Mor et al., 2016)
Growing need for hospice care within VA (Frahm, Barnett & Brown, 2011)

20. Prognostication May be used to establish goals of care
Survival predictors
Palliative Performance Scale
Tools (e.g., Karnofsky, ECOG) are poor predictors of survival
Biological markers
Clinician predictors
Estimating Prognosis (VHA, 2005)
Lynn, 2008; Quill, 2014; Weissman, 2015

21. Palliative Care
NQF, 2006

22. Two Palliative Care Frameworks for Guiding Care
Making and Keeping Promises:
Begin by envisioning what a better care system would look like (Lynn, 2000)
Quality of Life Model:
Identify physical, psychological, social, and spiritual aspects of care (Ferrell et al., 1991)

23. Making and Keeping Promises: Changing Systems of Care
Good Medical Treatment
Never Overwhelmed by Symptoms
Continuity, Coordination, & Comprehensiveness
Well Prepared, No Surprises
Customized Care, Reflecting Your Preferences
Consideration for Patient and Family Resources
Make the Best of Every Day
Lynn et al., 2000

24. Quality of Life Model: Addressing Four Dimensions of Care
Ferrell et al., 1991; Chovan et al., 2015

25. History of Palliative Care in VA
1992: Policy - “All Veterans should be provided access to a hospice program…”
: VA Faculty Leaders Project for Improved Care at End of Life
2001: Training and Program Assessment for Palliative Care (TAPC)
: TAPC launches VA Hospice and Palliative Care Initiative (VAHPC); VAHPC Launches Hospice-Veteran Partnership (HVP)
NHPCO, 2011

26. History of Palliative Care in VA (continued)
2003-Present: Palliative Care Consultative Team (PCCT); Accelerated Administration & Clinical Training (AACT)
2009- Comprehensive End of Life Care Initiative (CELC):
GEC Veteran Experience Center
GEC Implementation Center
GEC Quality Improvement Resource Center

27. Palliative Care Progress at VA
No Veteran Dies Alone Program (Chicago Tribune, 2016)
Reduction in cost with improved satisfaction (Penrod et al., 2010)
Shared Decision-Making and Advance Care Planning Worksheets
VA Goals of Care Conversation Training
Supportive care of families (Williams et al., 2011 & )
Improvement in nurse work environment and staffing contributes to quality of care
Partnership with National Hospice and Palliative Care Organization - We Honor Veterans

28. Role of the Nurse: Improving Palliative Care for All Patients
Nurses spend more time at the bedside than other healthcare providers
Some things cannot be “fixed”
Therapeutic presence and “being with”
First and foremost: Patient/family goals of care

29. Maintaining Hope in the Face of Death
Unique Opportunity
Excellent physical, spiritual care
Maintain hope
Processes
Experiential
Spiritual
Relational
Special consideration for Veterans
Cotter & Foxwell, 2015 ; Grassman, 2015

30. Extending Palliative Care Across the Continuum of Care
Nurses are the constant caregivers across settings
Expand the concept of healing
Become well-educated
Be willing to be a “change agent”
Coyle, 2015; Malloy, 2015

31. Summary Quality palliative care addresses quality of life
Palliative care and hospice models of care support the patient and family
Role of the nurse
Collaborative interdisciplinary care is essential
Many valuable resources for Veterans (NHPCO, n.d.d.;

32. Consider…
What steps do you need to take to improve palliative care at your institution so that you and other members of the team are prepared to meet the needs of seriously ill Veterans and their families?