Lesley Hirst, RGN (UK), RN, MN, MSc (c) on behalf of the Palliative Care Nurses Interest Group (PCNIG)
A day in the life

Mena assesses her patient Carole, a 59 year old with advanced ALS. Carole’s family are finding it difficult to cope with the rapid deterioration of her condition. They reflect on how just 18 months ago they were all on holiday together. Carole has been having periods of laboured breathing recently, and is unable to speak. Mena discusses reviewing her medication with her, about the goals they are hoping to achieve.

Mena spoke with Carole some months ago about how this disease would progress. They discussed how Carole would become dependent and rely on caregivers for all her needs. They talked about resuscitation, feeding tubes and where Carole would prefer to die. These conversations were difficult and emotional but supporting Carole and her family is important. Mena knows Carole’s wishes, as she can’t communicate directly with her. Mena transfers this information to the healthcare team and ensures the care plan reflects the goals of care and Carole’s wishes.
Mena reviews the medication, and speaks with the whole family about making the imminent decision to transfer Carole to hospice. Carole’s husband feels guilty because he wants to keep her at home but he is juggling a full time job and trying to support his children, who are both currently at university. He worries he is not administering enough pain medication and so he doesn’t sleep well wanting to check on her regularly. Mena listens to him and reassures him about all the amazing care he has provided. He looks to Carole and nods his head “ok then, let’s make the call and do the transfer this is what Carole wanted near the end”...

Background

There is a misconception that palliative care is only end of life care, whereas in fact end of life care is one component of palliative care. Palliative care as a specialty is still relatively new in Canada. In other areas of the world it is well recognized and established. Over the recent years here in Ontario many developments and initiatives have been seen, such as the CNA Certification in Palliative care through CHPCA (1) and new and exciting advanced roles such as the Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS), as well community based palliative care teams. The role will continue to develop and grow as the recognition of Palliative Care as a specialty does.

Specialty Education

Palliative care nurses are registered nurses with a baccalaureate degree in nursing. Certification in Hospice Palliative Care is available through the Canadian Nurses Association (CHPCN). The De Souza Institute (2) offers courses to prepare for the CNA certification exam. There is formal education available through various organizations throughout the province however Canada has not yet developed a specialist degree or diploma in Palliative Care like there is internationally. Local community colleges and universities may offer Palliative Care courses and certificates, as well as the provincial palliative care networks located in every LHIN (3). Cancer Care Ontario has also played a role in developing standards and researching palliative care through their integrated palliative care project as well as other initiatives.

Scope of Practice

As a RN, CNS, APN or NP, the nurse in palliative care will spend time focusing on a holistic approach to care delivery, attending to the physical, spiritual, psycho-social and practical issues that may arise during the illness period. The scope of practice is determined by their knowledge skill and judgment aligned within the regulations.

CHPCA (4) has developed practice standards for nurses working in palliative care. A NP works with an extended clinical scope of practice. Nine competencies have been identified within the CNA/CHPCN certification program which nurses should be proficient in.
They are: - Care of the person and family
- Pain assessment and management
- Symptom assessment and management
- Last days/hours/imminent death care
- Loss grief and bereavement support
- Interprofessional/collaborative practice
- Education
- Ethics and legal issues
- Professional development, and Advocacy

A palliative approach to someone living with a progressive, life-limiting disease is beneficial for all patients whether receiving active treatment or end of life care. The goals of care are concerned with excellent symptom management, be this in the physical domain or other, to promote comfort and quality of life.

Palliative Care Nurses collaborate with a range of members in the healthcare team from volunteers to palliative physicians, along with the Registered Dietitians (RD), Occupational Therapists (OT), Physiotherapists (PT), Social Workers and Chaplains, and together with the patient and family, the team collaborates to achieve the desired outcomes.

Practice Environment

There is a lot of diversity in the work settings for palliative care nurses. Palliative care is an approach to care for those who are living with a progressive life limiting disease, and so a palliative care nurse can work in an acute care setting, on an inpatient palliative unit, in the community visiting people in their own homes, in a long term care home or at a hospice. Palliative care nurses work a variety of populations, from children, and adolescents, to adults and the elderly population.

Clinical Laddering

Research in palliative care is still relatively new in comparison to other areas of nursing research. This is a potential area for growth for all RNs in all areas, community, acute care and long term care. More nurses are moving into ethicist roles which, is a unique area for a nurse with specialist education in this area. Opportunities are present for nurses to specialize in a disease site, e.g. breast cancer or in a particular domain e.g. spiritual care. Other opportunities are to pursue an advanced practice role with the completion of a Masters degree Clinical fellowships are also available through the RNAO for nurses who wish to work in palliative care.

Liability Protection

In some roles, extended or augmented liability protection may be required. These roles are likely to be those who are working as independent practitioners, Nurse Practitioners or other nurses working in advanced practice roles.

Current Status

RNs are providing care in acute care facilities, on medical floors, palliative care units and paediatric units, a number of community nursing agencies have specialized palliative teams. Hospice is an area f growth for practice. The expansion of the residential hospice in Ontario has facilitated multiple opportunities to work in this area.

Long term care is an area of current development of palliative care, recognizing the end of life care which is provided in this setting. Another departure from the traditional role is that of Case Manager (CM) especially within the CCAC (Community Care Access Centre), palliative CMs coordinate all the community services required to care for a person who needs palliative care in the homecare setting.

The roles of the Advanced Practice Nurse (APN) in palliative care are still poorly defined and recognized in Ontario. More of APN roles are becoming available as healthcare teams and administrators recognize the benefits of advanced practice in this field in collaboration with the entire team.

References
1 Canadian Nurses’ Association. (2009). Hospice Palliative Care Nursing Certification. CNA: Ottawa. Retrieved November 15, 2010 from: http://www.cna-nurses.ca/CNA/documents/pdf/publications/CERT_Hospice_200...
2 Ontario Ministry of Health and Long-Term Care, Cancer Care Ontario and University Health Network. (2010). Welcome to the deSouza Institute.deSouza Institute: Toronto. Retrieved November 15, 2010 from: http://www.desouzanurse.ca/
3 Provincial End of Life Care Networks. (2010) Ontario Hospice Palliative Care Networks. Toronto. Retrieved November 15, 2010 from: http://www.mhpcn.ca/uploads/Ontario_Hospice_Palliative_Care_Networks_-_D...
4 Canadian Hospice Palliative Care Association. Hospice Palliative Care Nursing Standards of Practice. CHPCA: Ottawa. Retrieved November 15, 2010 from http://www.chpca.net/norms-standards/palliative_care_nursing_standards.html

Palliative Care Nursing in Ontario