Abstract
Abstract
Background:
The Center for Medicare Services (CMS) requires palliative care involvement for patients who receive a destination therapy ventricular assist device (VAD). Creative solutions are needed to meet this requirement in the context of limited palliative care resources.
Purpose:
To evaluate a novel program in which a nurse conducts scripted pre-VAD visits to promote advance care planning and to triage the need for a full palliative care consult.
Study Design:
Prospective pilot study of patients undergoing evaluation for VAD.
Methods:
A script for pre-VAD visits was developed and pilot tested with patients. A registered nurse with basic palliative care training met with patients undergoing evaluation for VAD implantation. Data were collected regarding feasibility and acceptability of the intervention, need for full palliative care consults, and patient outcomes.
Results:
Between September 2014 and November 2015, the nurse conducted 37 visits. Thirty of the patients subsequently received a VAD. All participants completed the entire nurse visit. Six of the 37 patients required a full palliative care consult during the index hospitalization; these consults were for symptom management, psychosocial distress, or goals of care. Patients were more likely to discuss overarching values than preferences for specific medical interventions.
Conclusion:
Nurses with basic palliative care skills can conduct scripted preparedness planning conversations. These conversations are well received by patients, satisfy CMS requirements, and provide an alternative to full consults for resource-limited programs. Additional research is needed to compare outcomes between nurse visits and traditional consults.
Background
S
On October 30, 2014, the Center for Medicare Services (CMS) amended its requirements for destination therapy (DT) VAD centers to include involvement of a palliative care specialist. 5 In parallel, the Joint Commission (TJC) made palliative care involvement a requirement for DT-VAD Advanced Certification. 6 Neither CMS nor TJC delineates credentials or activities for the palliative care specialist, so programs are free to develop diverse protocols in partnership with local palliative care programs.
Although palliative care for all potential VAD patients is clinically appropriate, many palliative care teams have experienced rapid growth in consult demand.7–9 A national workforce shortage also limits the availability of palliative care specialists. 10 Some palliative care programs lack the resources to see all VAD candidates; other programs turn down competing consults to see VAD candidates. Creative, resource-efficient models are needed to provide high-quality palliative care to this patient population when palliative care resources are limited.
One potential opportunity is the use of nurses to conduct initial palliative care visits and to screen for more complex palliative care needs. Unlike physicians who may rotate on and off palliative care teams, nurses are consistently present and can establish ongoing relationships with the VAD team. Moreover, advance care planning and psychosocial support are within the scope of practice of registered nurses. If nurses can provide initial palliative care visits during the VAD evaluation process, full consults can be reserved for more complex needs such as conflicted goals of care, uncontrolled symptoms, or life-threatening complications.
The aims of this pilot study were to determine the feasibility and acceptability to patients, family members, and VAD clinicians of a scripted nurse-led protocol for pre-VAD palliative care visits.
Methods
Study design
We conducted a single-group pilot test of a newly developed protocol for the provision of palliative care to patients undergoing evaluation for VAD implantation.
Participants and setting
This study was conducted at a large, urban, tertiary medical center that participates in the TJC Advanced DT-VAD Certification Program. Before this study, palliative care did not see VAD patients except in the case of catastrophic complications and end-of-life needs. The inpatient palliative care consult team experienced rapid growth in the year before this study; 30% of patients with an active palliative care consult could not be seen due to staffing. The inpatient palliative care team was, therefore, unable to provide full consults for all DT-VAD evaluations to achieve compliance with TJC requirements. No outpatient palliative care for cardiovascular patients exists at this institution.
Protocol development
Based on a comprehensive review of literature, communication with VAD programs that have successfully incorporated palliative care into their evaluation process, and input from local cardiologists, a scripted palliative care assessment tool was developed (Table 1). The tool was designed to introduce the role of palliative care and to facilitate a conversation about advance care planning and possible adverse outcomes. The tool was also intended to identify patients in need of a full palliative care consult by a physician or nurse practitioner for the following indications: (1) uncontrolled symptoms, (2) psychosocial distress, or (3) uncertain goals of care.
CPR, cardiopulmonary resuscitation; VAD, ventricular assist device.
The nurse interventionist was an experienced registered nurse who underwent modest training. A palliative care physician conducted the first two pre-VAD visits using the tool while the nurse observed. The nurse then conducted three visits with support from the palliative care physician. At the end of this process, the nurse was comfortable in conducting visits independently, and the physician reviewed documentation to provide ongoing feedback.
Nurse visits were documented in narrative form in the electronic health record for review by the VAD team and other clinicians. The study protocol was reviewed by the VAD program's regulatory advisor to ensure compliance with CMS and TJC requirements. The use of patient data for this study was approved by the Institutional Review Board at the University of Pennsylvania.
Recruitment
All patients undergoing inpatient or outpatient evaluation for VAD placement during the study period were eligible. Given the pilot nature of this study, a convenience sample was chosen of patients who were available to meet with the nurse. The nurse included family members in the visit when present. The palliative care visit was introduced as part of the interdisciplinary VAD evaluation, but participants were free to decline participation. Recruitment was conducted for a total of 14 months.
Data collection
The nurse interventionist collected the following data from each study visit: patient demographics, setting for visit, and indication for VAD. If a full palliative care consult was initiated after the nurse visit, this was recorded along with the reason for the consult. The nurse then tracked each patient prospectively to record outcome of the VAD evaluation, disposition after index hospitalization, hospital readmissions, and future palliative care involvement.
Acceptability to patients and families was assessed using the two proxy measures of agreement to the nurse visit and completion of the entire script. Acceptability to VAD clinicians was determined through individual open-ended interviews with the medical director of the VAD program, a social worker, a VAD coordinator, and one other VAD team physician. At the conclusion of the pilot study, the entire VAD team was asked to suggest protocol modifications via e-mail.
Data analysis
Descriptive statistics were used to analyze the study nurse visits as well as the proportion of patients requiring full palliative care consultation. Research team members reviewed notes from VAD clinician interviews to identify themes regarding acceptability.
Results
Between September 2014 and November 2015, the nurse conducted a total of 37 pre-VAD palliative care visits (Table 2). This represents 76% of all the VAD implantations during the study period. Most visits occurred in the hospital a few days before VAD implantation, but some occurred in the clinic earlier in the evaluation process. The majority of patients were under consideration for VAD as DT (28/37, 75.6%), and this majority subsequently received a VAD (30/37, 81.0%).
Each patient may have more than one reason for consultation.
All potential participants agreed to the visit, and all patients completed the entire scripted visit. Most visits were 30 minutes to 1 hour in duration. Four patients and families (10.8%) requested ongoing support from the nurse after the initial visit. The palliative care nurse initiated a full palliative care consult for six patients (16.2% of visits). These consults were for symptom management, psychosocial distress, or uncertain goals of care, and all six subsequently received a VAD. The nurse provided pre-VAD visits independently in the remaining 31 cases (83.7%).
Feedback from the VAD team was uniformly positive. All VAD team members interviewed were familiar with the nurse and pilot protocol. All believed that the nurse visits were valuable and that patients received full palliative care consults when appropriate. No modifications to the protocol were suggested by the VAD team at the conclusion of the pilot study.
Discussion
A nurse-performed palliative care visit for VAD candidates was acceptable to patients, families, and the VAD program. Furthermore, this protocol effectively triaged palliative care needs, referring six cases with more complex needs for full consultation. In four cases, ongoing support was requested from the nurse.
This model is generalizable and within the scope of practice of registered nurses with basic training and mentoring. The visits are scripted and include a significant amount of anticipatory guidance, so nurses can refine their skills in advance care planning over time. Our palliative care nurse has become a local resource for VAD palliative care and participates actively in the weekly VAD selection meeting.
There is an acute national palliative care workforce shortage. 10 Many medical centers lack adequate resources to meet the CMS and TJC mandates for palliative care for DT VAD. These mandates do not define “palliative care specialist” or specify what constitutes acceptable involvement. Although some VAD candidates need the expertise of a palliative care specialist, it is likely that a nurse with basic palliative care training can meet the needs of the majority of patients. The primary team can address concerns raised by the nurse. An important aspect of the nurse's role, however, is the identification of patients who need a full palliative care consult. Our pilot study identified symptom management, psychosocial distress, and uncertain goals of care as triggers for full consultation.
Our study has several limitations. First, it used visit completion as a surrogate marker for acceptability of our intervention to patients and families. Structured evaluative surveys would have provided richer understanding of participant perception. Second, VAD team feedback was obtained through in-person conversations with a palliative care investigator, introducing the potential for bias. Third, our study was not designed to compare patient outcomes with nurse visits versus traditional palliative care consults. Results suggest that this protocol could be modified and tested in a larger randomized controlled trial to determine the effect on clinical outcomes, patient satisfaction, family satisfaction, and VAD clinician perception of palliative care services. Finally, we did not evaluate costs. Although these nurse visits are not billable encounters, they may lead to cost savings for institutions through avoidance of expensive interventions or lengthy hospitalizations at the end of life.
This model of palliative care nurse visits could be easily adapted to other high-risk populations such as patients awaiting transplant, candidates for transcatheter aortic valve replacement, or enrollees in clinical trials. Very few centers have adequate palliative care resources to extend full consults to all these patients, but specialized education could be developed to prepare nurses to conduct basic palliative care visits. As the palliative care community continues to grapple with issues of demand and workforce size, nurse-led advance care planning visits represent an opportunity to extend palliative care's reach in a novel, resource-efficient model.
Footnotes
Author Disclosure Statement
No competing financial interests exist.