Nurse Practitioner Palliative Aged Care (NP PAC) Case Study

Navigating A New Area Of Care and

Developing a Focussed, Achievable

Scope Of Practice

Jacqui Culver NP M.(Nurs.Prac);R.N.;RSCN.:B.Ed.;Dip.Couns.:Dip.F.L.Mgt;;TAA04

The Australian Nursing and Midwifery

Accreditation Council (ANMAC)

defines NP practice as:

'A nurse practitioner is a registered nurse educated and authorised to function autonomously

and collaboratively in an advanced and extended clinical role.

The nurse practitioner role includes assessment and management of clients using nursing

knowledge and skills and may include but is not limited to the direct referral of patients to

other health care professionals, prescribing medications and ordering diagnostic

investigations.

The nurse practitioner role is grounded in the nursing profession's values, knowledge,

theories and practise and provides innovative and flexible health care delivery that

complements other health care providers.

The scope of practice of the nurse practitioner is determined by the context of practice.‘

……………………. the theory

Context:

Cancer – person remains fairly well and then experiences a rapid decline – Often need Specialist Palliative Care for intense symptom management at end of life due to complexity.

Chronic Disease / Organ System Failure – person has periods of wellness with acute exacerbations when death may or may not occur – becoming more frequent towards end of life. The PAC NP, as a member of the primary health care team can coordinate end of life planning and care, referring to Specialist Palliative Care professionals if needed.

Dementia / Frailty – person has a very slow decline and a gradual shutting down of body and body systems. This can lead to a longer terminal phase as natural dying occurs through dehydration and multi organ / system failure. End of Life can be well supported within a primary health care model which includes the PAC NP .

Ruby:

Ruby was a 92 year old woman with

advanced dementia, living in

residential aged care. She had been

non verbal, heavily dependant for all

ADL’s and doubly incontinent for

well over12 months.

Her daughter noted a decline in

mobility and in swallowing capacity

and decided bring Ruby home to die

within her own home.

Ruby lived on for a further three

months and with advanced care

planning died peacefully in her own

home with her multi generational

family all around her.

Not one patient but many

Comorbidity of 10 common conditions among UK primary care patients2

BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341

(Published 4 October 2012)

Comorbidity

My Dad 88 years old – first diagnosed with Ischemic Heart Disease at aged 68 resulting in 6 CABG’s - further 3

CABG’s 4 years ago other wise fit and well until 12 months ago when he collapsed on the golf course.

Family history of Heart Disease: Father died of Heart Attack at 64 and Mother died of CHF at 70

Current Comorbidities:

Ischemic Heart Disease

Carotid Artery Disease

Right Heart Failure

Interstitial Pulmonary Fibrosis

Pulmonary Hypertension

Atrial Fibrillation / Arrhythmia’s

Syncope: Postural Hypotension

Cognitive impairment > Hypoxia

Chronic renal impairment

Medications:

Metoprolol

Perindopril

Digoxin

Frusemide

Spironolactone

Omeprazole

Warfarin

Vitamin D

Specialists: Cardiologist

Pulmonary

General Med

Vascular

Geriatrician

My Vision

• To empower nurses in reclaiming natural dying as a core nursing

priority not a medical condition. Liken to Midwifery . . . . . .

• To support elderly frail people and /or their loved ones, in making

informed quality of life (QOL) decisions about treatment options as

they approach the end of life.

• To have frailty and chronic comorbidity recognised as a complex

and unique speciality in its own right.

• To change the world – or at least my corner of it

Getting Started:

What would the role look like?

Where did the role fit:

- within HNE health?

- within the community / region?

- alongside existing services?

Was this primary care at a tertiary level or tertiary care at a primary level??

What did we want to achieve, what was possible to achieve and where could

we make the most impact on improved patient care, whilst ensuring future

sustainability within HNELHD?

Scope of Practice:

Unfamiliar environment:

• Complex comorbidity – chronic disease >multi

system failure, >longevity > frailty

• > dementia and chronic illness – greater

dependency, greater expectations, knowledge

• ‘Silo’ – specialities – including ‘specialist’

palliative care – ‘referral’ commonplace

• ‘Ageing in place’ v Community living/dying

Unfamiliar task:

• Advance Care Planning – preparing for a time

of reduced wellness, capacity and death.

• Clinical reasoning ++ Juggling symptoms

• Supporting ‘Dignity of Risk’, ‘Quality of Life’

‘Self Determination’ and ‘Natural Dying’

Unfamiliar environment

Familiar environment

Un

fam

iliar T

as

k

Fa

mil

iar

Ta

sk

Capability

Competency Advanced

Practice

Advanced

Practice

Nurse

Practitioner

Nurse

Specialist / consultant

Registered

Nurse

Reference unknown

Defining Boundaries of Practice

• Across two key specialities: Palliative and Geriatric medicine

• Across Sectors: HNE Health – Community NGO’s

• Across funding bodies: State and Commonwealth

• Across health providers: Acute, Private, Community, RACF’s

• Transitional process: from a curative to a palliative approach

• Multi speciality: cardiology, respiratory, vascular, renal,

rheumatology, neurology, oncology, psychogeriatric, general

medicine, endocrinology . . . . . . . . . . . . . .

• Highly vulnerable clientele with reduced capacity to self manage

health care and living within complex family systems.

• Ethical Issues: Poly-pharmacy, Futility of Treatment, Silo mentality

Reality Check

• Massive gap in service – one person

• Largest LHD in NSW

• Identified broad skill set of NP:

– Geriatric and Palliative Clinical Assessment

– End of Life care and symptom management

– Advanced Dementia Management

– Advance Care Planning Discussion

– Education and Training – Capacity Building

– Strong background in Aged Care Services

Centre for Healthcare Redesign HNELHD Palliative Aged Care Nurse Practitioner (PAC) Project

Project Aim: To develop a Model of Care for a

Nurse Practitioner in Palliative Aged Care.

Two colleagues also with a strong interest in this area applied for NSW

health funding for training in clinical redesign. They adopted the NP PAC

as their redesign project:

Lisa Shaw - ACP Coordinator Mandy Harden - CNC Aged Care

• 90% of audit

population identified

as ‘death not

unexpected’

• < 30% had EOL

discussion

documented in

medical record

• Audit population

used average of 5

community services

in last year of life

• No central record /

communication

process

Summary of Key Issues

Prognostication difficult for chronic

disease and frail aged clients

Poor health literacy for

client/family

Limited understanding of shared decision making process

Multiple service providers with

inconsistent care co-ordination

No plans for expected health deterioration /

EOL

• 70% of audit population had ACCR in place

• 25% of audit population transferred to hospital

from RACF and died in hospital

• Av LOS in final admission 3 days for 50% of

Audit population

• 25% of audit population had LOS 11-57 days

• Range from 1-5

hospital admissions

in final year of life

• Range from 1-8 ED

presentations in final

year of life

• Average of 7 co-

morbidities

• Dementia 3 x more common

then any other chronic

disease

• Limited understanding of

SDM role

Implementation of solutions to support MoC

Shared Care - Nurse Practitioner Palliative Aged Care, SPC and GPs

A Collaborative Approach

Person / Person Responsible

and other family members

Nursing, Allied Health

and Care Staff

Doctor, Geriatrician

Nurse Practitioner

Person Centred

Care

Person, Family & Care Team

‘Informed’ and shared decision making requires a

supportive multidisciplinary, collaborative approach.

Any discussion should be focused on realistic treatment

and care options that provide quality of life outcomes,

for the person experiencing the latter stages of their

disease trajectory.

Some topics that may be covered in an ACP discussion.

• Potential issues – i.e. Pain

• Futility of treatment

• Medication review

• Place of care at the end of life

• Environmental aspects

• Family involvement Nurse Practitioner - Shared Care Model

The PAC NP aims to work with the persons GP in shared care, so that any

aspect of care and treatment that falls outside the PAC NP’s scope of practice

can be referred back to the GP for monitoring or treatment.

Advance Care Planning Journey

Prognostication

Disease Trajectory

Information about

Legal & Ethical,

Planning ahead

What to expect

Signed

Medical Order re:

treatment preferences

Shared Decision Making

& Advance Care Planning

documented

Discussion

Case Conference

Person / Person

Responsible / Family

Nursing &

Care Staff

GP/Medical

Officer /NP

Multidisciplinary

Team

Person Centred

Care

Person, Family & Care Team

The circle of life

Thank you