DNA Reporter - December 2021

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Page 6 • DNA Reporter December 2021, January, February 2022 COVID-19 Pandemic Through the Lens of an Inpatient Palliative Medicine Provider Heather M. Milea, MSN, FNP-BC, AGACNP-BC, PCCN, CHFN Heather M. Milea is currently a nurse practitioner on the palliative care team at Christiana Care Hospital where she has worked for over twenty years with an acumen in family medicine, advanced heart failure, and cardiology. She is a graduate of the University of Delaware’s undergraduate baccalaureate nursing program and Master of Science in Nursing program with a concentration in family nurse practitioner. She completed a post-master’s graduate degree at the University of Pennsylvania in adult gerontology acute care. Heather has been recognized as one of the 2021 top nurse practitioners by Delaware Today, is a member of the Delaware Coalition for Nurse Practitioners, and serves on the palliative team wellness committee and transition team at Christiana Care Hospital. Heather may be reached at hmilea@christianacare.org. Heather M. Milea The COVID-19 pandemic systemically obstructed the delivery of traditional healthcare, particularly impacting our chronically ill and frail patients. Healthcare delivery for the hospitalized, critically ill COVID-19 cohort was challenging because of the complex symptom management, rapid physical decline, high mortality, and increased intensive care utilization (Rosa et al., 2020). As the virus infiltrated Delaware, this problem was further aggravated as our healthcare organizations followed the isolation strategies established by other institutions: significant restrictions in visitation, limiting the flow of providers in and out of rooms, and segmenting COVID-19 patients from other patient populations. Despite the obvious public health need to reduce transmission of the respiratory pathogen, an illconsidered byproduct was the social isolation, severing our instinct to be present with loved ones during a serious illness. With the isolation increasing our patients’ suffering and our efforts to provide holistic care frustrated, care delivery models had to be radically revised as the palliative medicine team innovated and tested our processes in real time. As the expression goes, we were “building the plane as we flew.” Palliative Medicine During a Pandemic Palliative medicine providers are holistic by virtue of the discipline. Through disease counseling and goals of care for acute, chronic, or traumatic health problems, palliative medicine’s foundational ethos is to improve quality of life both inside and outside the biomedical realm, as well as reduce the burden of symptoms related to disease states. The diverse team of inpatient palliative care service providers including physicians, nurse practitioners, physician assistants, social workers, nurse navigators, and palliative chaplains collaborate to add robust, holistic care. Communication prowess is one of the revered skillsets among palliative providers, especially during end-of-life care (Pattison, 2020). The World Health Organization’s (WHO) 2018 ethical principles in humanitarian contexts strongly advocate for access to palliative care to minimize suffering and, by the United Nations International Health Regulations’ own definition of “public health emergency of international concern,” the COVID-19 pandemic would most certainly qualify. As the pandemic disintegrated traditional healthcare delivery, inpatient palliative care consults for COVID-19 patients surged. Among the significant symptom burden of a hospitalized COVID-19 patients, anxiety and loneliness may be among the most hidden and difficult to resolve, even in optimal healthcare scenarios. In an environment where care teams and resources were burdened, and intensivists and nurses occupied the limited bedside to provide care, the palliative medicine team had to reinvent how to expedite care for this vulnerable, often frail, population. That revitalized care model was discovered in what originally gave our team strength: our multidisciplinary teamwork. Multidisciplinary Palliative Medicine Team and Virtual Management To bridge the gap of visitor restrictions, our team implemented off-the-shelf, consumer technology (i.e., iPads) equipped with videoconferencing platforms in COVID-19 rooms and at nursing servers. The care team worked “virtually” for inpatient visits, allowing for high-touch care in limited-touch environments. Trained, Horizon House is a nationally recognized provider of services to adults with support needs due to developmental disabilities, behavioral health issues and substance abuse. Nursing Career Opportunities Registered Nurse | Licensed Practical Nurse Certified Nursing Assistant Wilmington, DE and Newark, DE Qualified candidates should forward their resumes to edith.boyd@hhinc.org Building on 70 years of experience, we have been dedicated to helping people. Horizon House offers competitive compensation and a comprehensive benefit package. Grow with us in helping a better future together at https://www.hhinc.org/ Horizon House is an EEO Employer-M/F/V/D/Sexual Orientation, Gender Identity medical language translation specialists and cultural consults were brought on to provide culturally competent care. The palliative medicine team now had an option to facilitate our exacting, rapport-dependent care for our patients and family, extending our ability to supply support and connection. Unfortunately, despite institutional support for the technology program, family stakeholders did not have universal access to platforms for virtual visits, forcing many difficult conversations to take place via telephone. In this context, the absence of important, nonverbal cues diminished the quality of interaction, especially regarding difficult, end-of-life communications. Vulnerable stakeholders had to trust a medical team to help with emotionally overwrought decisions without the comfort of connecting to their loved ones. Serious Conversations “Ordinary” critically ill scenarios can limit time to have meaningful healthcare conversations on the values and wishes of the patient. The often precipitous decline that can happen with COVID-19 hospitalized patients further compacted the time to prepare patients and their care circle. Often, that involved standing outside an ICU room of a COVID-19 patient struggling with fear, providing through the glass a calm voice of comfort, an ear to listen, or a provider who could treat symptoms of air hunger, anxiety, or even claustrophobia. The palliative medicine team elected to implement best practices from COVID-19 conversation guides. VITALtalk (n.d.), a nonprofit social impact organization for clinicians, encouraged early and clear communication, as well as exploring patient goals and making care recommendations based on those stated goals. For the team, discussions with the patient and their support system regarding prior advance care planning documents, anticipatory guidance of swift clinical deterioration, and code status ensued immediately into a hospitalized patient’s COVID-19 course. With those that were fortunate to survive the acute phase of their inflammatory-related respiratory failure, the palliative medicine team counselled patients on the trajectory of the longterm sequalae of COVID-19, including fibrotic lung disease, coagulopathies, cardiomyopathies, debility, and failure to thrive. The work was a delicate balance of active listening and support to spouses, children, and care circles physically separated from their sick family members. For patients that passed without a loved one near, our nurses held their hands. End-of-life Care for COVID-19 Patients Amidst a Global Pandemic Suffering, end-of-life COVID-19 patients are most treated for dyspnea, restlessness, anxiety, and delirium, along with significant spiritual and psychosocial needs. Dyspnea and delirium are among the most common symptoms in dying patients with COVID-19 and, despite attempts at managing underlying cause of dyspnea, refractory dyspnea and hypoxia may persist (Sun et al., 2020). The Center to Advance Palliative Care (n.d.) developed crisis protocols for managing common symptoms associated with COVID-19, which our team follows. Opioids are the treatment choice for refractory dyspnea and as-needed dosing is safer and more effective compared to an opioid infusion. Non-pharmacologic interventions include sitting the patient in either an upright or, in some instances, prone position. The decision in favor of COVID-19 ventilation focuses on limiting lung damage and mitigating aerosolization of the virus. In circumstances where continuing aggressive care was futile or where goals of care dictated de-escalating or withdrawing ventilation support, the ICU and palliative teams initiate end-of-life discussions to guide a compassionate withdrawal of care with an emphasis on a dignified passing. Preparing the family is imperative; expectations, suggestions, and exploration of their concerns are important to ameliorate prior to withdrawal of care. Hospice resources for family and their care circle is robust, not only during their hospice care, but also in bereavement support that extends after their loved one’s passing. The palliative team’s principle is to provide physical, spiritual, and psychosocial comfort for our patients and their extended care circle. During the COVID-19 pandemic, the collaboration with primary and specialty services complimented the front-line workers who were brave enough to support our community. Moreover, just as we do for patients, the palliative medicine team offers safe haven to support colleagues without prejudice. There have been far too many tragic losses related to COVID- 19 and, as a society, we share a collective and complicated grief that we have not yet begun to unpack. References Center to Advance Palliative Care (n.d.). COVID-19 rapid response resources hub. https:// www.capc.org/covid-19/ Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus (COVID-19) pandemic. Intensive and Critical Care Nursing, 58. https://doi.org/10.1016/j. iccn.2020.102862 Rosa, W.E., Meghani, S.H., Stone, P.W. and Ferrell, B.R. (2020). Opportunities for nursing science to advance patient care in the time of COVID-19: A palliative care perspective. Journal of Nursing Scholarship, 52(4), 341-343. https://doi.org/10.1111/jnu.12570 Sun, H., Lee, J., Meyer, B. J., Myers, E. L., Nishikawa, M. S., Tischler, J. L., & Blinderman, C. D. (2020). Characteristics and palliative care needs of COVID-19 patients receiving comfortdirected care. Journal of the American Geriatrics Society, 68(6), 1162–1164. https://doi. org/10.1111/jgs.16507 VITALtalk (n.d.). COVID Ready communication playbook. https://www.vitaltalk.org/wpcontent/uploads/VitalTalk_COVID_English.pdf World Health Organization (2018). A WHO guide: Integrating palliative care and symptom relief into the response of humanitarian emergencies and crises. https://apps.who.int/iris/ bitstream/handle/10665/274565/9789241514460-eng.pdf
December 2021, January, February 2022 DNA Reporter • Page 7 Community-Based Palliative Care: High Quality and Cost Effective Ginna Keil, MSN, FNP-BC Ginna Keil earned her Associate of Arts Degree in General Studies in 2002 followed by her Associates of Science Degree in Nursing in 2006 from Wor-Wic Community College. Ginna was a registered nurse in the State of Maryland and Delaware for 13 years with nursing experience in the emergency department, women and children’s health, and neonatal intensive care settings. Ginna furthered her education by receiving her Bachelor of Science Degree in Nursing and graduated with her Master of Science Degree in Nursing from Wilmington University in 2018. Certified by the American Academy of Nurse Practitioners, Ginna practices as a Family Nurse Practitioner in the State of Delaware. Ginna currently is employed with Delaware Hospice and provides Palliative and Hospice services in the Ginna Keil community setting. Professional achievements include member of the Phi Theta Kappa-Honor Society, Daisy Award Recipient, Maternal Child Award, Nursing Service Excellence Awards, and Delaware Hospice Star Award. Ginna may be reached at gkeil@delawarehospice.org. Widely known among healthcare providers are the challenges today’s Healthcare system face secondary to an expanding aging population who suffer serious illness compounded by multiple medical comorbidities. According to data provided by the Center to Advance Palliative Care (CAPC, 2015), there are at least 12 million adults and 400,000 children in the United States living with a serious illness and by the year 2030, people aged 85 and over are expected to double to 8.5 million. The Delaware Healthcare Association (DHA, 2019) reported that emphasis on disease specific treatments have become commonplace rather than holistic treatment that addresses the needs of patients and their caregivers. In many cases, this focus has led to fragmented and burdensome care with inadequate management of symptoms resulting in unnecessary suffering. It is, therefore, a system that is unsustainable in terms of poor quality and high cost. The question then becomes, ‘how does the Healthcare system meet the needs of this growing population while still delivering high quality and financially sustainable care?’ (CAPC, 2015). A potential solution may lie in the specialty of palliative care medicine which has been growing in popularity globally over the last two decades. What is palliative care? With a unique holistic approach that is both patient and family centered, the Center to Advance Palliative Care (2019) explained that the design of palliative care is to anticipate, prevent, and manage physical, spiritual, social, and psychological aspects of health and improve the quality of life for patients, families, and caregivers throughout their illness trajectory. Furthermore, based on patient need rather than diagnosis, any individual regardless of age who are diagnosed with a serious illness may receive palliative care services alongside curative treatment. Although services may be initiated at any stage of the illness trajectory, implementation in the early stages of the disease process have resulted in improved patient care outcomes. As leaders in healthcare recognize the impact that cost effective and high-quality palliative care have on patients, caregivers and healthcare organizations, services are now available in 94% of hospitals with more than 300 beds and available in 72% of hospitals with more than 50 beds (Center to Advance Palliative Care, n.d.). Inpatient palliative care consultation is associated with a reduction in healthcare costs with a total savings of more than $1.3 million for a 300-bed community hospital and more than $2.5 million for the average academic medical center (Cruz-Oliver, 2017). Expansion of palliative services is a Healthcare necessity and should be offered on every level and across all settings in efforts to meet the many needs of Americans living with serious illness compounded by multiple medical comorbidities (CAPC, 2021). Hospitals and health systems are now extending palliative services into community settings including but not limited to physician offices, ambulatory clinics, cancer centers, skilled nursing facilities, and patient homes. In addition to hospitals and health systems, service delivery is provided by primary care physicians, specialty practices, private companies, home health aid agencies, and hospices (CAPC, n.d.). Palliative care is multidisciplinary and includes a team of dedicated medical, nursing, and allied health professionals. The comprehensive role of the palliative care team throughout the trajectory of the patient’s illness includes but is not limited to expert pain and complex symptom management, provision of psychological, spiritual, and emotional support, medication management and monitoring, and the completion of advance health directives. The palliative care team works collaboratively with specialists in the community that allows for coordination of care. As the trajectory of illness progresses, locations as well as wishes of the patient and their caregivers may change. Community based palliative care allows for consistency across transitions (CAPC, 2021). Community based palliative care allows for a reach to patient populations that neither fit hospice eligibility nor are hospitalized and are stable enough to reside in the community setting. Many individuals suffering from serious illness and chronic medical conditions experience mobility issues with functional limitations that do not allow travel to office settings or are burdensome. Often, it is the preference of many individuals suffering from chronic medical conditions to remain at home while coping with their serious illness. The National Coalition for Hospice and Palliative Care (NCHPC, 2018) explained that with disease progression, the emphasis shifts from active treatment of the disease to treatment that promotes comfort with an improved quality of life. Anticipatory guidance is provided regarding disease process, progression, and strategies for management in efforts to optimize quality of life. They further explained that palliative care providers facilitate patient autonomy, by providing access to information and choice regarding their care. Palliative care in the home setting promotes the development of a trusting rapport and fosters feelings of support and connectivity. This allows for sensitive conversations of how individual values, preferences, ethnicity, culture, and spiritual beliefs play a role in their healthcare (NCHPC, 2018). The Center to Advance Palliative Care, (2021) recognizes that there is strong evidence that implementation of community based palliative care services results in compassionate, affordable, sustainable high-quality care, and is associated with reduced nonbeneficial emergency department visits and hospitalizations. Reduced hospital readmissions may lead to reduced penalties for hospitalized patients with serious chronic illnesses. Where do hospitals in the State of Delaware stand regarding equitable access to palliative care services? Delaware Healthcare Association (DHA, 2019) President & CEO Wayne A. Smith stated, “Delaware hospitals are proud to lead the nation in providing access to quality palliative care for our friends and neighbors” (para. 3). Delaware hospitals were leading the nation in 2019 by providing individuals living with a serious illness equitable access to palliative care services according to the 2019 State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals (DHA, 2019). The integration of palliative care services promotes the high quality and financially sustainable care needed to meet the physical, spiritual, social, and psychological needs of patients and their caregivers who suffer serious illness. Leaders in Healthcare nationwide must strive to integrate palliative care medicine into healthcare systems and ensure that patients from all populations and across all settings receive this invaluable service. References Center to Advance Palliative Care. (2015). A guide to building a hospital-based palliative care program. file:///C:/Users/ginna/Downloads/the-capc-guide-tobuilding-a-hospital-palliative-care-program.pdf Center to Advance Palliative Care. (2021). Concepts of community-based palliative care program design 101: Learner’s Guide. file:///C:/Users/ginna/Downloads/conceptsof-community-based-palliative-care-program-design-101-learners-guide.pdf Center to Advance Palliative Care. (2019). Key findings on the perceptions of palliative care. https://media.capc.org/recorded-webinars/slides/1lessAudience_Research_ Webinar_Aug_8-2019_FINAL.pdf Center to Advance Palliative Care. (n.d.). The case for community-based palliative care: A new paradigm for improving serious illness care. file:///C:/Users/ginna/ Downloads/the-case-for-community-based-palliative-care.pdf Cruz-Oliver D. (2017). Palliative Care: An Update. Missouri Medicine, 114(2), 110 –115. Delaware Healthcare Association. (2019). Delaware receives top “A” grade on access to palliative care in our nation’s hospitals. https://deha.org/News/Press-Releases/ Delaware-Receives-Top-A%E2%80%9D-Grade-on-Access-to-Pallia National Coalition for Hospice and Palliative Care. (2018). National Consensus Project for Quality Palliative Care. https://www.nationalcoalitionhpc.org/ncp Injury Attorneys Rhoades & Morrow is Dedicated to Helping Nurses With Their Legal Needs Handling Personal Injury & Workers’ Compensation Matters Serving All of Delaware With Offices In Wilmington, Bear, Milford and Lewes www.rhoadeslegal.com • (302) 427-9500
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DNA Reporter - December 2021

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