jacqueline culver,hunter new england health district: navigating a new area of care and developing ...
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Jacqueline Culver, Nurse Practitioner Palliative Aged Care, Hunter New England Local Health District delivered this presentation at the 2013 Developing the Role of the Nurse Practitioner conference. The event is designed for organisations and managers looking to better understand, utilise and grow the role of the nurse practitioner in their health service. For more information about the annual event, please visit the conference website: http://www.healthcareconferences.com.au/nursepractitionersconferenceTRANSCRIPT
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