Working as a Specialist Palliative Care Nurse Practitioner in RAC
A blog post written by Peter Jenkin, Nurse Practitioner (Palliative Care), Resthaven Incorporated
Nurse Practitioners (NP) work in many roles in residential aged care: general primary care, wound care, memory disorders, mental health, heart failure and palliative care.
A Nurse Practitioner is a Registered Nurse who has completed both advanced university study at a Masters Degree level and extensive clinical training to expand upon the traditional role of a Registered Nurse. They use extended skills, knowledge and experience in the assessment, planning, implementation, diagnosis and evaluation of care required.1
As far as I know, I am still (unfortunately) the only specialist palliative care nurse practitioner employed by an aged care provider in Australia. Why is that you ask? Primarily it comes down to money. NP services are not funded via the aged care funding system (ACFI), and the income I can generate from bulk billing residents via Medicare covers only a small proportion of my salary. So it relies on an organisation like Resthaven seeing the non-monetary benefits and improved outcomes that stem from a role like this.
My role ‘adds value’ to what is normally done very well by GPs, nurses and other members of the aged care team. Sometimes I do 'fill a gap' when the GP is unavailable but the prescribing and other extended activities remain secondary to the specialist nursing focus I bring to clinical encounters. More often, I’m there to help when things get complicated.
A good example is 86 year old 'Beth', who lives with severe heart failure. She collapsed and was resuscitated six months ago and subsequently had a pacemaker inserted. Sincer then her function had declined leading to multiple falls and increased care needs. She now needs two people to assist with transfers and is increasingly sleepy during the day. A 1.2 litre fluid restriction and numerous medications were keeping her breathlessness and oedema 'relatively' stable. She was referred by frustrated nursing staff who were having difficulty managing her increasing insomnia and more general agitation and distress. This was being treated with benzodiazepine sleeping tablets that left her sleepy during the day, especially when given in the early hours of the morning. Multiple cups of hot chocolate at night were also playing havoc with her fluid restriction.
A benefit of my role is the ability to undertake longer and more in-depth consultations, not only undertaking a comprehensive history and examination from the resident, but also reading back through months of clinical notes and talking to the family, doctor, nurses and care-workers. This enables a 'big picture' view of the situation that can yield information not always evident to staff involved with the day-to-day care.
In Beth's case, this led to the discovery that while not depressed, her agitation and trouble sleeping was primarily due to anxiety about her failing physical health. She disclosed, for the first time, her fear of not being able to finish writing her life story on her beloved computer. This was so important to her that she expressed a desire to be hospitalised (and even be resuscitated again) if it gave her more time. This is despite her written advance care directive stating a wish for 'palliative approach' to all care.
So what did I contribute to a solution:
- Giving Beth the opportunity to express her concerns and fears.
- Facilitating a conversation with her family about her desire to temporarily amend her advance care directive.
- Amending her care plan so Beth was given the opportunity to sit at the computer each morning for as long as she could tolerate.
- Teaching relaxation/breathing techniques and sourcing a handheld fan to use when anxious/breathlessness.
- Getting her radio fixed so she could listen to talkback at night.
- Providing education to the nurses and careworkers about the assessment and management of existential/emotional distress.
- Prescribing a trial of melatonin as an alternative to sedating benzodiazepines.
My role allows me to spend the time needed to facilitate and take part in conversations, less encumbered than GPs for whom ‘time is money’, or RNs who are usually responsible for 50 or more residents on a shift. “...done well, these conversations are the engine that drives the elucidation and treatment of suffering...".2
And my approach remains firmly rooted in the nursing paradigm. It is an autonomous role but not independent, relying on collaboration with all members of the health care team.
As a palliative care nurse practitioner who works within the aged care organisation, I am not just an external consultant, making suggestions and hoping for the best. The ability to provide direct care, model best practice and influence clinical practice improvement increases the opportunity for improved outcomes for the older people and their families we care for.
Three years ago this month I was endorsed as a Nurse Practitioner. Would I do it all again, knowing what I do now about the study and work needed? Absolutely. It’s the best job I’ve ever had!
[1] ACNP 2016 What is a Nurse Practitioner? https://www.acnp.org.au/aboutnursepractitioners
[2] Weiner J , Roth J. Avoiding Iatrogenic Harm to Patient and Family while Discussing Goals of Care Near the End of Life. J Palliat Med. 2006;9(2):451-463. https://www.ncbi.nlm.nih.gov/pubmed/16629574
Peter Jenkin is a Nurse Practitioner (Palliative Care), Resthaven Incorporated