advanced practice nursing: pioneering practices in...

Advanced Practice Nursing:Pioneering Practices in Pall iative Care

Promoting excellence in end–of–life careA NATIONAL PROGRAM OFFICE OFThe Robert Wood Johnson Foundation

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Promoting Excellence in End-of-Life Care, a National Program Office of The Robert Wood Johnson Foundation

Table of Contents

2 INTRODUCTION

4 ADVANCED PRACTICE NURSING: PIONEERING PRACTICES IN PALLIATIVE CARE

18 TRAINING FOR THE FUTURE

20 CONCLUSION

AcknowledgementsThis publication was produced by PromotingExcellence in End-of-Life-Care, a national programoffice of The Robert Wood Johnson Foundation,Primary authors of this report are:

Julie Emnett, Communications OfficerIra Byock, MD, DirectorJeanne Sheils Twohig, MPA, Deputy Director

A special thanks to Jennifer Matesa for her assis-tance in writing this report, and to the advancedpractice nurses featured in this report for spendingcountless hours to ensure this project’s success.

Completing the Picture of Excellence

In 1997, The Robert Wood Johnson Foundationlaunched a national program Promoting Excellencein End-of-Life Care with a mission of improvingcare and quality of life for dying Americans andtheir families. We soon realized that the metaphorof a jigsaw puzzle seemed apt in describing ourefforts to expand access to services and improvequality of care in a wide range of settings andwith diverse populations. No single approachwould suffice—a variety of strategies, models ofcare, and stakeholders are necessary to successfullycomplete the picture. This monograph representsone aspect of our work and one piece of thepuzzle of ensuring that the highest quality ofcare, including palliative care, is available to allseriously ill patients and their families.

July 2002

4 URBAN TRAUMA/EMERGENCY CENTERPALLIATIVE CARE SERVICE DETROIT RECEIVING HOSPITAL DETROIT, MICHIGAN

6 ACUTE CARE TEACHING HOSPITALPALLIATIVE CARE SERVICEMASSACHUSETTS GENERAL HOSPITALBOSTON, MASSACHUSETTS

8 URBAN RESEARCH CANCER CENTER SUPPORTIVE CARE PROGRAMPAIN AND PALLIATIVE CARE SERVICEMEMORIAL SLOAN-KETTERING CANCER CENTERNEW YORK, NEW YORK

10 LARGE INNER-CITY HOSPITAL SERVING A DISADVANTAGED URBAN POPULATIONNEW JERSEY UNIVERSITY HOSPITALNEW JERSEY MEDICAL SCHOOLNEWARK, NEW JERSEY

12 A UNIVERSITY-AFFILIATED GERIATRIC PRACTICESCHOOL OF NURSING AND SCHOOL OF MEDICINEUNIVERSITY OF NORTH CAROLINA–CHAPEL HILLCHAPEL HILL, NORTH CAROLINA

14 RURAL PRIMARY CAREADJUVANT THERAPIES, INC. LAKE, MICHIGAN

15 RURAL PRIVATE PRACTICEPALLIATIVE CARE CONCEPTS, INC.GREENVILLE, OHIO

17 LONG-TERM CARE FACILITYCARVER LIVING CENTERDURHAM, NORTH CAROLINA

18 GRADUATE NURSING EDUCATION IN PALLIATIVE CARE URSULINE COLLEGETHE BREEN SCHOOL OF NURSINGPEPPER PIKE, OHIO

19 PALLIATIVE CARE NURSE PRACTITIONER PROGRAMNEW YORK UNIVERSITYDIVISION OF NURSINGNEW YORK, NEW YORK

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In July 2001, Promoting Excellence in End-of-LifeCare, a national program office of The RobertWood Johnson Foundation, convened a group ofadvanced practice nurses (APNs) to discuss thestate of palliative care advanced practice nursingin the United States, to identify gaps in andbarriers to that practice, and to develop strategiesfor the future. The report from this day-and-a-half-long meeting, Pioneering Practices inPalliative Care, has three objectives: to facilitateconversation among nursing leaders about howto improve the state of palliative care advancedpractice nursing, to illustrate successful modelsof pioneers in advanced practice nursing and topromote the advanced practice nurse’s role inproviding palliative care.

Principles of Palliative CareA primary tenet of palliative care is that clinicalprofessionals be aware of and respect patients’treatment wishes. Although preferences varyaccording to race, ethnicity and religion, mostAmericans—more than 90 percent in a recentGallup poll—wish to be in their own homes orin a homelike setting when they die. Unfortun-ately, barely 20 percent of Americans die athome.

Other principles of palliative care, such asattention to physical comfort and personaldignity, pertain regardless of where a dying

person resides.Certainly, the 80percent of Americanswho die in institutionsneed—and deserve—expert symptommanagement andattention to personaland interpersonalaspects of life closure.(See sidebar "What isPalliative Care?")

The Impact of an AgingSocietyAt the start of the 21stcentury, the oldest ofAmerica’s 76 millionbaby boomers are intheir mid 50s and theyoungest are approachingage 40. As advances inmedical technology

continue to extend life, these aging Americans willhave to contend with the aches, pains and pro-gressive disabilities of chronic illness. The needfor specialized palliative care to improve comfortand quality of life for this population is great—and it is growing. Policymakers, payers andconsumer groups must encourage the developmentand application of better tools and strategies forbringing palliative care to more Americans.

Nursing LeadershipBy articulating and asserting their values andvision, nurses can positively influence publicdiscourse and social policy on caring for the mostill, infirm and aged Americans. Nurses arepresent in every setting where Americans receivecare. In many health care facilities, it is a nursewho sees and evaluates patients first. Even whena patient dies at home, a home health or hospicenurse has been overseeing the person’s care.

Advanced practice nurses play a critical rolein expanding access to services and improvingquality of care for patients with advancedchronic illness. By facilitating coordination andmaximizing continuity of care, APNs are notonly particularly helpful to patients and families,but also highly valued by their clinical colleaguesand administrators.

Palliative care is an approach to care that

addresses the patient’s physical, emo-

tional, social and spiritual needs and

seeks to improve quality of life not only

for the ill person, but also for his or her

family. Palliative care is provided by

interdisciplinary teams of professionals,

often including physicians, nurses, social

workers, chaplains or spiritual coun-

selors, and other health care disciplines.

APNs: Improving Quality and Access toPalliative Care In communities and health systems nationwide,APNs with specialized training and experiencein palliative care are leading the effort toimprove access, promote clinical excellence andimprove cost effectiveness. In addition, advancedpractice nurses are contributing to healthservices research in palliative care, oncology,neurology, critical care, surgery and pediatrics.

APNs: Valuable Members ofInterdisciplinary TeamsPalliative care advanced practice nurses oftencan provide patient care and family supportthroughout the continuum of care and diseasetrajectory. Practicing as members ofinterdisciplinary teams, APNs work with:

• Patients and families: APNs use listen-ing skills to learn the full spectrum ofpatient and family concerns and toserve as patient/family advocates.

• Physicians and the palliative care team:APNs contribute to diagnostic evalua-tions and treatment. They also modeland mentor effective modes of caring.

• Facility administrators: APNs managethe delivery of valuable health careservices at the point of patient contact.Working within institutions andcommunities, APNs reach those inneed while managing resources in anefficient, cost-effective fashion.

What’s InsideThis report provides a window into the practicesof APNs who specialize in palliative care. Thepractice settings described span the spectrumfrom hospital-based to independent practice toacademia. Most of the featured pioneering APNswork as part of an interdisciplinary clinical team;others work in private practice or as consultantsto teams or physicians.

As this monograph illustrates, APNsspecializing in palliative care effectively andcompassionately address the needs of patientsand families who are experiencing life-threatening illness. They exemplify both thescience and art of nursing by coupling expertknowledge and clinical judgment with respect,dignity and care. By melding basic human valueswith the pragmatism needed to be effective intoday’s environment, APNs are an invaluableresource as we strive to care for our nation’s ill,infirm and elderly.

Introduction

What is Palliative Care?

URBAN TRAUMA/EMERGENCY CENTERPalliative Care Service Detroit Receiving Hospital Detroit, Michigan

Detroit Receiving Hospital (DRH) has maderemarkable strides in providing palliative care toits patients. Meg Campbell, a nurse practitionerwho currently leads the DRH Palliative CareService, began her career in critical care nursingin the early 1970s when the field was expandingrapidly. “We were learning how to keep peoplealive who would ordinarily die, but we didn’tknow which patients would actually benefitfrom these procedures,” Campbell recalls. “Donot resuscitate (DNR) orders were rare at thetime, and it was not unusual to resuscitatepeople again and again in hopes of bringing themback from the brink of death. Intuitively, weknew which patients would die, but we didn’tknow what else to do.”

When the opportunity presented itself,Campbell accepted the challenge of providingpalliative care to patients at DRH, which is anurban tertiary care center. “I knew it was what Iwanted to do. I already had excellentcommunication skills and a critical carebackground,” she explains. The past 13 yearshave proven her right. Today, Campbell asserts,“Palliative care is the best work I’ve ever done.”

Palliative Care as a SubspecialtyIn Michigan, APNs have considerable independenceas care providers—including prescription-writingprivileges. Although APNs have to work with a

physician to prescribe Class II medications, directsupervision is not needed. “We can provide whatpatients need at the time they need it. Thatmakes all the difference in the APN’s role and inpatient care,” Campbell explains.

DRH’s Palliative Care Service, which isintegrated into the entire hospital, is considereda subspecialty. “I focus on patients who are notexpected to survive their hospital stay,” saysCampbell. “It doesn’t matter what disease orinjury a patient is dying from or where in thehospital he or she is.”

Campbell intervenes when a patient has anuncertain or poor prognosis. Using predictormodels, she assists the medical team in recog-nizing the patient’s prognosis and then identifiesappropriate interventions. Campbell assesses thepatient and explores the value of palliative carewith the medical team. She also workscooperatively with the hospital’s pain service.

DRH serves mostly indigent patients whotypically do not have a primary care provider. Inmost cases, there are no previously establishedphysician/patient relationships. “In about 85percent of cases, the attending physician andresident team sign off on the patient when wesign on,” Campbell explains. She provides atraditional consult service for the other 15percent of patients whose physician and residentteam wish to continue writing orders anddirecting care. Campbell’s Palliative Care Serviceis solely hospital based. A small number ofpatients, fewer than 10 percent, are dischargedfrom the hospital to receive ongoing home-basedor facility-based palliative care via hospiceproviders in the community.

Although Campbell does not have a standingpalliative care team, she insists she hassomething even better. “I have access to anyone Ineed from the hospital or university,” sheexplains. “Unlike the hospice model in whichteam members are fixed, the hospital-basedpractice at Detroit Receiving is just me—but Ican involve a chaplain, social worker, dietitian,psychologist, wound specialist or whomever thepatient needs.”

Early hospital data showed that even thoughCampbell was seeing 40 percent of non-traumapatients, her interventions were coming later inthe illness or injury course than optimal—thisdespite efforts to educate medical staff regardingthe benefits of early palliative care. In recent years,however, Campbell has focused on finding casesrather than waiting for referrals. Before startingher case-finding effort, she was seeing 27 percentof patients who needed palliative care. Now, shesees nearly 100 percent of eligible patients.

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Funded by Cost SavingsCampbell is a salaried employee of the hospital,which bills for patient care, but not specificallyfor Campbell’s services. Most patients arecovered by Medicare or Medicaid. The hospitalfunds Campbell’s position because of the costsavings associated with avoiding unwanted andexcessive treatment and unnecessary ICU days.Hospital data suggests that her interventions aresaving, on average, five ICU days, and more than$5,500 per patient.

Campbell is constantly collecting cost data onthe effect of the Palliative Care Service. “I’vekept a data set to justify the impact of thepractice,” she says. “I can show how the numberof consults impacts the institution’s bottom line.”Campbell notes that collecting data has pre-served the program at times when budget cutsresulted in the elimination of other programs.

Education and EmulationCampbell orients all new hospital nursing employ-ees, introducing them to the Palliative Care Service,explaining what she does, and letting everyoneknow when and how to reach her. She also teachesnursing students at local colleges and universitiesand is an assistant professor of medicine at WayneState School of Medicine in Detroit, where sheparticipates in the ethics course taught tosecond-year medical students. In addition,Campbell presents cases at the department ofinternal medicine’s morning report, lectures ingrand rounds, and conducts bedside teachingwith nurses and physicians at every consult.

Campbell explains that other hospitals inDetroit and in Michigan have put similarprograms in place. One of Campbell’s advancedpractice nursing graduate students started aprogram at St. Joseph Mercy Hospital in Pontiac.The Fairview Health System in Minnesota is alsoemulating Campbell’s model.

Personal ReflectionIn addition to collecting financial data, Campbellalso assesses patient satisfaction. “The way I knowit’s working is when the family can relax and evenjoke, when they can sit together and tell stories toone another,” she explains. “Some people laugh,others cry, but they no longer fret. They knowwhat is going on and that the patient is comfortable.When that happens, I know all is going well.”Campbell also has one other measurementmethod: “I practice in the most litigious countyin the state, and, despite the fact that so many ofour patients die, we’ve never been sued.”

The advanced practice registered nurse has

a master's or doctoral degree and has

concentrated in a specific area of advanced

practice nursing. She or he has had super-

vised clinical training in a specific area of

practice at the graduate level as well as

ongoing clinical experience. An advanced

practice registered nurse may be a clinical

nurse specialist (CNS), nurse practitioner

(NP), nurse anesthetist (CRNA) or nurse

midwife (CNM).

Meg Campbell, RN, MSN, FAAN

What is anAdvanced Practice Nurse?

American Nurses Association. (1995a). Scope and Standards of

Advanced Practice Registered Nursing. Washington, D.C.:

American Nurses Association.

Advanced Practice Nursing:Pioneering Practices in Palliative Care

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ACUTE CARE TEACHING HOSPITALPalliative Care ServiceMassachusetts General HospitalBoston, Massachusetts

Ten years ago, Massachusetts General Hospital(MGH) was not the place one would expect tofind expert palliative care. MGH is a premieracademic teaching hospital that prides itself oncutting-edge, life-saving medical treatments.Thanks in large part to the efforts of ConstanceDahlin, however, palliative care has also beenincorporated into MGH’s daily activity.

Dahlin, a palliative care clinical nurse specialistand nurse practitioner, was one of the firstmembers of the MGH palliative care team whenit began in 1996. Today, in addition to Dahlin,the team includes two attending physicians, twophysician fellows in palliative care training, asocial worker, a bereavement/volunteercoordinator and an administrative assistant.

The MGH team provides a consulting servicefor patients who have life-threatening diagnoses

and are in need of symptom management,psychosocial support, grief and bereavementcounseling, discharge planning, and/or long-termcare planning. The patients served need not beactively dying. The goal is to alleviate sufferingand develop a plan of care that enables patientsto return to their own communities with hospiceor home health services and ongoing supportfrom the Palliative Care Service. “It’s my job tomake sure that each patient’s needs are met atevery stage of his or her illness,” Dahlin explains.

Continuity of CareIn about 25 percent of cases of patients with life-limiting illness, the Palliative Care Service takesover primary care duties, often at the request ofthe physician. The team can devise plans of careand write medical orders. Dahlin and hercolleagues often meet jointly with these patientsand their physicians to ease any feelings thepatient might have about being abandoned byhis or her physician.

The continuity of care provided by thepalliative care team is a key factor in its success.“We have a policy of continuing to check withpatients and families,” Dahlin explains. “The goalis for care to be as seamless as possible fromhospital to home or hospice.”

The team dedicates time and effort towardanticipating and preventing problems for patientsand families and discussing issues such as advancedcare planning, bereavement and other familyissues. “We can take whatever time is necessaryto deal with problems,” says Dahlin. “We haveexpertise in pain and symptom control that canbe very valuable to the patient. We help peopleget what they want,” she continues. “We are theiradvocates.”

The program was easily accepted because itschampion, Andy Billings, MD, currently medicaldirector of Palliative Care Service, had arelationship with the hospital as a primary carephysician and hospice medical director. Theprogram started slowly, but has grown, both inpatient numbers and in case complexity. “We arebuilding relationships, and people are judging usby the care we provide,” says Dahlin, who strives

to have a presence on the floor. As Dahlin putsit, she does “curbside consults.”

Dahlin is credentialed to provideconsultations at the hospital, at an affiliatedrehabilitation facility, in an independentoncology rehabilitation setting and at a nursinghome. She bills under Medicare, Medicaid andthird-party HMOs. Her salary is divided betweenthe hospital budget and a physician’s group.

Educational InteractionsThe Palliative Care Service conducts weeklyrounds on issues in end-of-life care andparticipates in weekly cancer-pain rounds,monthly ALS rounds and occasional oncologyrounds. Dahlin and her team also hold weeklypalliative care rounds on the oncology floor,psychosocial rounds and nursing rounds.

Dahlin serves as preceptor for graduate andundergraduate nursing students. She also runstwo hospital workshops on pain managementand palliative care, teaches continuing educationcourses for students and conducts in-serviceworkshops as needed. “Every interaction is achance for education,” Dahlin explains, “and youcan’t take those opportunities lightly.”

Formal family satisfaction surveys havedemonstrated that the Palliative Care Service isappreciated. A clinician survey revealed that theservice has been invaluable in difficult situationsand has resulted in a quicker transition to lesscostly therapies. Dahlin’s experience at MGH istestimony to the fact that APNs are an importantlink in providing care to patients across thecontinuum of care from the hospital to home.

Personal Reflection“Being a nurse practitioner in a palliative carerole is especially rewarding,” Dahlin notes. “I’mable to work in an advanced practice capacitywith all of the expertise that is involved and stilluse my nursing skills to be attentive to thehuman needs of my patients. I feel empoweredto do whatever is necessary to help patients helpthemselves at a very critical time in their lives.”

In addition to direct involvement with

dying patients, APNs in palliative care act

in a variety of other roles. They can be:

• Designers of innovative practices for

end-of-life care in a variety of settings.

• Educators of and consultants to other

clinicians, medical residents, nursing

students and other providers.

• Researchers who make important

contributions to the professional

literature and body of knowledge.

• Administrators within health care

systems, institutions and clinical

education programs.


Roles of thePalliative CareAdvanced Practice Nurse

Constance M. Dahlin, RN, CS, MSN, ANP

URBAN RESEARCH CANCER CENTERSupportive Care ProgramPain and Palliative Care ServiceMemorial Sloan-Kettering Cancer CenterNew York, New York

The Supportive Care Program at MemorialSloan-Kettering Cancer Center (MSKCC) bridgesthe gap between hospital and community care. Itprovides continuity of intensive palliative carefor cancer patients and their families who arebeing followed by the hospital’s Pain andPalliative Care Service and who are returninghome. The program extends the team concept bybringing the expertise of a comprehensive cancercenter, including a commitment to palliativecare, into the community. There is no charge topatients or their families for this service.

Most patients with progressive, debilitatingcancer have palliative care needs. Some are athigh risk for poorly controlled pain and otheruncomfortable symptoms. Some also sufferheightened psychological distress when they aredischarged back into the community. Thesepatients and their families are referred to theSupportive Care Program for intensive follow-up.Patients with advanced disease may fit thehospice admission criteria. Those who do not,however, may benefit from a parallel system ofcare that focuses on life-prolonging therapy aswell as aggressive palliative care. Both types ofpatients and their families are followed in theMSKCC Supportive Care Program.

Caring for Patients at HomeThe purpose of the program is to provide expertpalliative care to patients at home. Manyprogram patients, though not all, live within thefive boroughs of New York. Because most of theteam’s work is done via telephone, however,location is not an issue. The APN is available viatelephone 24 hours a day.

The program provides a link between MSKCCand community health practitioners working withprogram patients. The program APN, with supportfrom the MSKCC Pain and Palliative Care Serviceinterdisciplinary team, facilitates continuity ofcare and, as requested, offers symptom controlexpertise to community clinicians.

The program also acts as an expert resourcefor patients, families and health professionalsthroughout the country who care for cancerpatients with pain and other symptoms.In addition, it offers education and support fornurses and physicians who are increasingly facedwith the care of chronically ill and dying cancerpatients who have complex symptoms andfamily members who are exhausted and grieving.

A Collaborative EffortThe MSKCC Supportive Care Program is acollaborative effort among APNs, physicians andsocial workers. Consulting team members comefrom psychiatry, rehabilitation, nutrition servicesand chaplaincy. Other MSKCC resources are also

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Certification in hospice and palliative

nursing is offered at the generalist level

through The National Board for

Certification of Hospice and Palliative

Nurses Association. An advanced

practice palliative care certification

examination is being developed through

a partnership of the American Nurses

Credentialing Center and the National

Board of Hospice and Palliative Nurses

Association. The examination will be

available for nurse practitioners and

clinical nurse specialists in spring 2003.

available to the program’s APN coordinator andthrough her or him to the patient, family andcommunity team.

APNs Nessa Coyle and Mary Laymen-Goldsteinwork with a caseload of 12 to 15 patients each.Their salaries are paid through the Departmentof Neurology and are considered part of MSKCC’sclinical overhead. Each year, they make orreceive approximately 3,200 telephone calls, 40home visits, 200 outpatient clinic visits and 600hospital visits. The small number of annualhome visits is testimony to the fact that theSupportive Care Program works with thecommunity home care team and is not intendedto replace local clinical teams and practitioners.

The length of time that patients and familiesare followed varies from weeks to years.Intensity of involvement also varies, dependingon need, from multiple telephone contacts in aday to weekly contact or even less. Althoughpatients may be in a hospice program, they oftenrequire an ongoing relationship with theSupportive Care Program if their symptoms areparticularly complex. Some patients may notmeet hospice admission criteria but havepalliative care needs, nonetheless. Others maydecline to join a hospice program.

Personal Reflection“This is a wonderful and personally enrichingarea to work in,” Coyle says. “I am constantlylearning from patients and their families. Towork in this field, you need to have a goodgrounding in symptom management and thedomains of suffering. You also need the ability tolisten. Patients and their families are our constantteachers,” Coyle continues. “Listen and you willlearn what they need. They will also teach youabout living and dying.”


Nessa Coyle, RN, MS, NP, FAAN

Palliative CareCertification

LARGE INNER-CITY HOSPITALSERVING A DISADVANTAGEDURBAN POPULATIONUniversity of Medicine and Dentistry of New Jersey–University HospitalNew Jersey Medical SchoolNewark, New Jersey

APN Patricia Murphy heads the University ofMedicine and Dentistry of New Jersey–UniversityHospital’s (UMDNJ) interdisciplinary End-of-LifeConsultation Service. Murphy started the servicein 1999. Prior to coming to UMDNJ, she workedat Beth Israel Medical Center in Newark, whereshe chaired the ethics committee.

Other members of the End-of-Life ConsultationService include a Baptist minister, two master’s-prepared death and dying counselors, and an ethicist.A surgeon and an oncologist participate on anas-needed basis. Murphy sees patients and theirfamilies every day concerning pain, grief andethical questions.

The End-of-Life Consultation Service is unlikemany hospital palliative care services in that itembraces a broad range of services from middle-of-the-night acute bereavement support to complexethics consultations regarding treatment decisionsfor patients who may have no burdensome symptoms.Murphy, who is EPEC trained (Education forPhysicians on End-of-Life Care), is a salariedemployee of the hospital. Clinical servicesprovided by the End-of-Life ConsultationService are billed to third-party payers.

Palliation for Trauma VictimsThe consultation service received a jump-startfrom a series of grants that permitted Murphy tohire staff. Later, Murphy and Ann Mosenthal, MD,a trauma surgeon, were awarded a joint Projecton Death in America faculty scholar grant. Theirproject was to identify trauma patients who wereactively dying and provide them with palliativecare. Their success was startling. Word spreadwithin the hospital and soon nurses, physiciansand patients’ families began to ask for the End-of-Life Consultation Service. “People startedcalling when they could see that we weremaking a difference,” Murphy says.

As this monograph illustrates, APNs can

receive several forms of reimbursement

for their services.

Direct reimbursement for APN services

can come from several sources. APNs

can bill Medicare at 85 percent of the

rate physician’s receive. To be reim-

bursed, an advanced practice nurse must

collaborate with a physician and be cer-

tified as an advanced practice nurse by a

national organization. A master’s degree

will be required by 2003 to receive

reimbursement from Medicare. APNs

can bill Medicaid for reimbursement,

but the rules and rates vary from state to

state. Other third party payers, such as

insurance companies, usually reimburse

APNs for clinical care.

APNs are also often on salary in medical

institutions that bill for APN-provided

services. Furthermore, in a number of

institutional and practice settings, partic-

ularly capitated or federally financed

safety net health systems, APN’s salaries

can be financed through cost avoidance

of unnecessary hospitalizations or ICU

days or through improved system effi-

ciency resulting from their involvement

in palliative care.

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Working with the Palliative Care and PainService at Beth Israel Medical Center, Murphyand Mosenthal developed standing orders foractively dying patients. University Hospital’sTrauma Service incorporated the orders, andthey are now accepted hospital-wide for alldying patients. In addition, Murphy regularlyconducts pain and ICU rounds. “As residentsrotate through the End-of-Life ConsultationService,” Murphy notes, “they learn that there isa better way to care for patients near the end oflife and their families.”

Because the program has been developedwith grant support, sustaining the team and itsclinical services will be a challenge. In an inner-city hospital serving a large population ofimpoverished patients, the cost savings resultingfrom the team’s interventions should more thanpay for the program’s costs. Murphy is collectingthe data to prove this hypothesis. So far,anecdotal evidence indicates that the program isgetting people out of the ICU more quickly, isresulting in the use of fewer resources and isdecreasing the number of patients in nursinghomes in a vegetative state.

Murphy believes that anyone with sufficientdrive, a readiness to work long hours—at least inthe beginning—and knowledge of painmanagement can put together a palliative careteam and promote the use of standard orderforms. She acknowledges, however, that much ofher team’s impact on the system is due to thecommitment and tenacity of her colleagues.

Personal Reflection“Many of the patients at our hospital aremedically underserved,” Murphy explains. “Forsome, our service is their first exposure topalliative care. Many people write to us aboutthe excellent care they or their loved onesreceived here.”

Patricia Murphy, PhD, APN, FAAN


Paying for APN Services

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A UNIVERSITY-AFFILIATEDGERIATRIC PRACTICESchool of Nursing and School of MedicineUniversity of North Carolina–Chapel HillChapel Hill, North Carolina

Martha Henderson practices as an adult nursepractitioner and geriatric nurse practitionerthrough the Program on Aging at the Universityof North Carolina–Chapel Hill (UNC). A self-proclaimed “end-of-life care facilitator,” she helpsfill the health care and communication gapsoften faced by the chronically ill elderly.Henderson is a Project on Death in Americafaculty scholar. Her special area of expertise isadvanced care planning. Her doctoral dissertation,Beyond the Living Will, explores results from astudy showing that discussing end-of-life prefer-ences lowered death anxiety in a sample ofretirement community elderly.

Generally, the patients Henderson serves havefallen through the cracks, being ineligible forhome care and hospice, and have advanced

chronic illness, such as end-stage heart and lungdisease, dementia or cancer. Because theirprognosis and trajectory for dying is fairlyuncertain, they may not meet hospice’s six-month criterion. In addition, many ofHenderson’s patients do not see themselves asterminally ill. Henderson also cares for peoplewhom home health won’t see because they can’tmeet the strict criterion of being homebound.

Delivering the BasicsHenderson provides five basic services. She callsin professional colleagues as needed to ensurethat these services are available:

• Assessment: Henderson assesses thepatient’s function and the adequacy ofcurrent living arrangements, includingcaregiver support.

• Symptom management: Hendersondoes what is necessary to ensure thatchronic illness is treated at themaximum level possible and/or thatcomfort care, including drug therapy, is

provided. She also asks patients what ismost important to them and how theywant to use their limited time and energy.

• Advanced care planning: Hendersondefines advanced care planning as a“process in which people begin to thinkabout their mortality, what’s importantto them and how they want to die.” Shehelps her patients write an advancedcare plan, including appointment of asurrogate decision maker and thecompletion of an advanced directive, ifthat is what they desire.

• Emotional, social and spiritualcounseling: Henderson helps patientsdeal with their own grieving and lettinggo of life. She may treat depression oranxiety with medication andcounseling. Henderson also helpspeople come to terms with dying,which often involves listening, prayingand reading scripture. She may make areferral to a pastor, priest or rabbi tohelp the patient maximize his or herown resources for spiritual support.

• Continuity, coordination and communi-cation: Henderson stays with a patientand family from admission until thepatient dies. “This means that every timethe patient changes settings, they havea familiar face—a care provider whoknows them medically and personally,”she explains.

Referrals to Henderson come from hospice,primary care providers, friends, nursingcolleagues and through UNC’s Program on Aging.The amount of care given depends on patientneed. Some of Henderson’s patients are stableand require only monthly visits. When patientsare unstable or actively dying, however,Henderson may see them frequently or mayrefer them for hospice care.

Henderson is supported by the UNC’sDepartment of Medicine, which donated 20percent salary for her position to care forchronically ill adults who don’t qualify forhospice or home care but need additionalassistance to improve their quality of life.

Although Henderson has had the financialsupport of the Program on Aging and the UNCDepartment of Medicine, the lack of fullreimbursement for her time through MedicarePart B makes long-term support for her positionan uncertainty. Currently, she receivesreimbursement for about 50 percent of her time.Thus, some of her “behind the scenes” telephoningto family and physicians, work with the familyand coordination of services is not reimbursed.

Focus on EducationHenderson speaks, consults and conductsworkshops throughout the United States. Sheteaches physicians, nurses and other healthprofessionals how to help their patients preparefor death. Her advanced care planning facilitatorcourse is designed for those who want to learnhow to talk to people about what they want atthe end of life. She and her colleagues havedeveloped a worksheet to guide an advanced careplanning discussion in the primary care setting.She also consults with hospice providers. Inaddition, Henderson is helping to educate othernurse practitioners about end-of-life carethrough participation in palliative care efforts ofthe American Academy of Nursing and in herrole as chair of the End-of-Life Care Task Forcefor the American College of Nurse Practitioners.

Personal Reflection“I do everything possible to keep patientscomfortable and help them fulfill some of theirdreams,” she explains. “I try to help them find joywithin the confines of their illness.”

“Our evidence of success is the satisfaction ofpatients and families,” Henderson says. “Eachfamily completes an evaluation after the death oftheir loved one. These evaluations are alwaysvery good and show the family’s gratitude.”Physicians also seem satisfied with Henderson’sefforts to improve patient care. “As long as I keepcommunicating with doctors about importantchanges in their patients, they are always veryappreciative of the care I provide,” she notes.


Martha L. Henderson, MSN, MDiv, DrMin, GNP

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RURAL PRIMARY CAREAdjuvant Therapies, Inc. Lake, Michigan

Kim Kuebler started Adjuvant Therapies, Inc., asa community-based primary care practice with anemphasis on palliative care. Her practiceillustrates the potential role for the advancedpractice nurse in providing continuity andcoordination of care for patients living with anddying from advanced illness. Kuebler is an adultnurse practitioner and clinical specialist inoncology who serves as a primary care providerfor her patients. She focuses on integratingpalliative care into traditional health services forthe underserved, sparsely populated, ruralcommunity of Lake in central Michigan(population: approximately 25,000). Kueblerpatterned her practice model after GreatBritain’s Macmillan nurses, who are trained tocomplement physicians and public health nursesin providing continuous, coordinated care forpeople with advanced, incurable illness and fortheir families.

Kuebler follows her patients throughout theirillness, helping them and their families make thetransition to palliative care as their diseaseprogresses and the end of life nears. She providescase-managed care by accessing appropriatecommunity and specialty physician referrals tomeet individual patient and family needs. She alsofocuses on secondary prevention of problems towhich patients with chronic illness are prone.

As a nurse practitioner, Kuebler performscomprehensive physical examinations, orders andinterprets diagnostic tests and prescribesmedications. Because APNs in Michigan cannotprescribe Class II medications, such as opioidanalgesics, Kuebler has a collaborative practicearrangement with two internal medicinephysicians who can prescribe appropriate painmedications based upon her assessment andrecommendations.

Kuebler carries an average patient census of350 active patients; approximately 45 to 50 areseen in their homes. Eighty-five percent of thecare Kuebler provides is palliative in nature. “Ifollow patients back into their home setting,” sheexplains, “making sure they have the services thatthey need, including physical, occupational orrespiratory therapy, skilled nursing care, seniorservices and/or hospice care.” Kuebler makes manyweekend home visits to prevent crises and respondto exacerbations of pain and other symptoms.

In addition to her collaborative practicearrangement with the internal medicinephysicians, Kuebler also works with a clinicalpsychologist and a massage therapist. Whenpatients are referred to hospice, Kuebler directstheir medical management and continues to seethem until their death. She also attends hospiceinterdisciplinary team meetings. Kuebler billsunder traditional codes and receives reimburse-ment from Medicare, Medicaid and third-partypayers. She bills for her services as a nursepractitioner in private practice, independentfrom hospitals, clinics or long-term care facilities.

Getting StartedKuebler says that starting her practice has notbeen without difficulties. “It’s been hard,” shereports. “At first, other providers resented a nursepractitioner working in the community. I strug-gled for hospital privileges and met constantlywith the CEO and with local physicians.”

During her three years of service, Kuebler hasseen more than 2,000 patients. Some of heroriginal patients are still alive and continue to

derive comfort from Kuebler’s services. Patientswho have died under her care have commonlybeen served by hospice for six to eight months,far exceeding the national average for hospicelength of stay. “My patients are not abandoned.They continue to see me until the end,”Kuebler explains.

“I started out as a hospice nurse,” she continues.“I understand case management and make surethat my patients are not falling through thecracks, that all of their needs are addressed andthat services are based upon individual preferences.My patients and their families are very satisfied.By making routine phone calls to my patients, Iensure that any emerging problems are caughtearly and managed.”

Sharing the Knowledgeand ExperienceKuebler opens her doors to undergraduate andgraduate nursing students from all over theUnited States. To date, 10 graduate students haveworked side by side with her for up to threedays. She also takes two or three local associate-degree nursing students on home visits duringeach semester.

Recently, Kuebler was funded by the MichiganDepartment of Community Health to work inpartnership with the Michigan Nurses Associationto produce palliative care self-training productsand a clinical consultation Web site. Theseresources will be integrated into six graduatenursing curricula in Michigan and within theVeterans Administration nationally.

Kuebler and her colleagues also publishedEnd-of-Life Care Clinical Practice Guidelines(W.B. Saunders), the first textbook of its kind toaddress evidenced-based clinical aspects ofpalliative care for the advanced practice nurse.

Kuebler believes that anyone can emulate hermodel. “I’m not creating any new reimbursementstructure,” she says. “I am using traditionalreimbursement codes while demonstrating aspecialty in palliative practice. I am able toprovide continuity and coordinated care in acost-effective fashion.”

Personal Reflection“Persevere” is the single most important piece ofadvice Kuebler offers to nurses interested inpursuing a career similar to hers. “What you haveto offer is unique. It does make a difference andimproves patient outcomes,” she says.

RURAL PRIVATE PRACTICEPalliative Care Concepts, Inc.Greenville, Ohio

Michelle Hobbs, a family nurse practitioner, ispresident of Palliative Care Concepts, Inc., anindependent practice headquartered inGreenville, Ohio, the county seat of rural DrakeCounty (population: 53,309). In Ohio, nursepractitioners can provide comprehensive healthassessments, diagnose and manage acute andchronic illnesses, order and interpret diagnosticstudies, and formulate care plans to manageillness and promote wellness.

In her practice, Hobbs provides pain andsymptom management, assists with advancedcare planning, assesses emotional needs, offerspsychosocial and spiritual support, and identifiesand accesses community resources. She hasprescriptive authority through a pilot project atWright State University in Dayton, Ohio, and isrequired to practice within a collaborativeagreement established with one or morephysicians. “I’ve focused my practice on palliativecare for patients of all ages and in all settings,”explains Hobbs, who sees her patients whereverthey are—at home, in a nursing home, in thehospital or in an assisted-living facility.

Hobbs is the only nurse practitioner on themedical staff at Wayne Hospital in Greenville,Ohio. Patients are referred to her by physicians,who consider her services an extension of thecare they provide, or by nurses and socialworkers in hospitals and nursing homes. Patientsalso call her directly after hearing about herservices from a friend or reading about her in thelocal newspaper.


Michelle A. Hobbs, RN, MS, CNP

Kim Kuebler, MN, RN, ANP-CS

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LONG-TERM CARE FACILITYCarver Living CenterDurham, North Carolina

Jennifer Gentry uses her nurse practitionertraining and specialization in palliative care toprovide medical care for the residents of CarverLiving Center (CLC), a 272-bed long-term carefacility in Durham, North Carolina. One of thelargest nursing homes in the state, CLC offersshort-term rehabilitation, long-term care andhospice care. “Our motto is function andcomfort,” Gentry explains. “In everything we do,we ask how it will benefit the patient— and howit will make the patient more comfortable ormore functional.”

As a nurse practitioner in North Carolina,Gentry is able to act independently as an on-siteprimary care provider for facility residents. Ratherthan waiting for a patient’s doctor to visit or fora clinic appointment, Gentry can evaluate andtreat a CLC patient with minimal delay. Often,problems that might have required emergencytreatment and hospitalization are averted.

CLC’s progressive medical director, William F.Uthe, MD, has worked closely with Gentry tointegrate palliative care into the normal flow ofclinical care at the nursing home. Rarely does aweek go by without a family meeting to discussissues of palliative care and to determine whatsteps should be taken to ensure a resident’scomfort and continuing excellent care.

Careful Case Management Case management begins the moment patientsare admitted to the CLC. For new patients,Gentry performs the admission, takes thepatient’s medical history, and writes orders forlab tests and for an initial plan of care. Forexisting patients, she examines, diagnoses andtreats whatever medical problems occur. Part ofher routine includes discussing patient prefer-ences for care and advanced directives, either atthe time of admission or shortly thereafter.

People are admitted to CLC from thehospital, from home and from hospice. At times,it is clear that the patient being admitted hasonly a short time to live. In these cases, Gentryconvenes a meeting with the physician andfamily. “I sit down with family and review thepatient’s advanced directive,” she explains. “Wetalk about what to expect. Everyone is different,and taking individual differences intoconsideration is one of the secrets to success.”

Financial ViabilityCarver Living Center bills Medicare, Medicaid,private insurance and patients for Gentry’s acutecare services. Her salary is covered by reimburse-ment, thus allowing the facility to recoup theexpense of a full-time care provider. Gentry hascollected data showing that CLC nursing homeresidents make significantly fewer trips to thehospital emergency room than average, resultingin lower patient costs and a less stressful atmos-phere in the facility. In addition, hospice referralshave tripled since Gentry joined the facility.

Collaboration at WorkThe philosophy of palliative care is implementedat CLC through the day-to-day, hands-on caregiven by attending physicians, a second nursepractitioner, a physician assistant and a socialworker. In addition, Gentry has worked hard todevelop collaborative relationships with areamedical specialists to improve access to servicesfor CLC residents. For instance, a local neurologistnow holds a clinic at the facility six times a year.

Gentry frequently consults with the CLCnurses at the bedside. “I validate their nursingskills and teach them techniques of palliativeassessment and care,” she explains. She alsoconducts in-service training for staff, teachesnurse practitioners and resident physicians, andserves as a mentor for nurse practitioner studentsfrom University of North Carolina–Chapel Hilland from Duke University.

Personal ReflectionCLC’s success story is traveling by word ofmouth. “Several times a year I get a phone callfrom a nursing home administrator who wants tolearn how we improve people’s lives,” Gentrysays. “Our model is self-sustaining and relativelyeasy to implement with the right kind ofleadership and support.”

Overcoming the ChallengesHobbs overcame some major hurdles when shestarted her practice two years ago. “I was one ofthe first nurse practitioners in this county andthe very first to start an independent practice,”she explains. “Many people were unfamiliar withnurse practitioners, and palliative care was notwell understood.”

With the support of local physicians, Hobbsbegan to provide an additional service—a wellness program that helps patients newlydiagnosed with chronic, potentially terminalillnesses stay as well as possible while living withprogressive disease. Patients and caregivers in thisprogram are educated about their specific diseasecondition, medications and plan of care. Patientsalso participate in advanced care planning toensure that their wishes are always honored. Inaddition, Hobbs introduces patients and familiesto community resources that can assist withpractical needs. She also conducts a Care for theCaregiver class, in which she teaches how to carefor an ill loved one and offers practical advice tocaregivers in dealing with their own psychosocialand spiritual concerns.

The majority of Hobbs’s patients reside innursing homes. She has provided consultation insix area nursing homes to ensure that patientsreceive adequate pain and symptommanagement. She is now working with thesenursing homes to implement a demonstrationproject designed to build palliative care teamsand change policies and procedures to provide afull range of palliative care services.

Paying for PracticeAfter two years, Hobbs’s practice is self-supporting, sustained by reimbursements andfee-for-service revenues, and is not underwrittenby any medical institution. She has her ownMedicare and Medicaid provider numbers andbills patients or their third-party payers directlyfor consults and care. Some HMOs do not reim-burse any nurse practitioner services, howeverHobbs has found this exclusion to be rare.

Extending a Successful ApproachThrough Education and ServiceHobbs believes that nearly 100 percent of herpatients experience some improvement in theirsymptoms. “My patients and families feel morein control in a very out-of-control situation,” shesays. “In the past, patients have had to choosebetween aggressive curative treatment or

comfort-oriented care. Palliative care brings thosetwo ends of the spectrum together, allowingpatients to be comfortable from the time theyare diagnosed with a potentially terminal illnessthrough the moment of their death.”

Hobbs, who chairs the pain committee atWayne Hospital, has presented many paineducation seminars. She is also a member of thefaculty at Wright State University, where she isexploring ways to weave palliative care intoundergraduate and graduate nursing curricula.Hobbs has conducted research examining painassessment and treatment in cognitively impairedelderly and has given a number of seminars inOhio on this topic. She has also presented a Web-based teleconference for the Hospice andPalliative Nurses Association and serves as anexpert on the association’s “Ask the Expert” Webpage.

She believes the Wayne Hospital model isideal for implementation in rural communitieswhere no one health care organization or facilitycan support a full palliative care program.Palliative care services led by a nurse practitionercan be woven throughout the existing healthcare structure of a small community.

Personal ReflectionHobbs advises nurses exploring APN practice ofpalliative care to “know you can make a hugedifference in people’s lives. APNs have asignificant body of knowledge, experience andexpertise. Our autonomy allows us to care forpatients and families in truly innovative waysand fill gaps in the current health care system.”


Jennifer Gentry, RN/C, MSN, APN

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GRADUATE EDUATION INPALLIATIVE CAREPalliative Care ProgramUrsuline CollegeThe Breen School of NursingPepper Pike, Ohio

Denice Sheehan, a clinical nurse specialist,coordinates the palliative care track in themaster of science in nursing program at TheBreen School of Nursing at Ursuline College inPepper Pike, Ohio. This graduate program is thefirst in the United States to prepare clinicalnurse specialists in palliative care. The firstcourse was offered during the summer of 1997.

Sheehan based the Ursuline program on anational and regional needs survey indicatingthat palliative care nursing experts supported theneed for graduate education in palliative care.This support was echoed by Ursuline Collegenursing alumnae and Cleveland nursing leaders.The program started with nine students and nowenrolls 23 in the palliative care track and post-master’s certificate program.

Building a PartnershipSheehan, who has extensive clinical experiencein oncology and hospice, decided that palliativecare needed to be included in the graduate nursingcurriculum. “We needed a partnership amongstudents, clinical agencies and faculty,” she explains.

Ursuline students learn three ways: classroomwork, interaction with experienced nurses and anopen-door faculty policy. “These three elementsplus reflection and contemplation are thestrengths of our program,” Sheehan explains.“Our educational program is based on values.Students learn about themselves first by looking

at their own values. Then they are able to listenand learn about patient values and provide carebased on patient and family needs.”

Communication is another program focus.Students learn how to talk with someone who isdying. “Over time,” Sheehan says, “they come tosee dying as a potentially rich experience andgain perspective on their own beliefs on themeaning of life and their own direction in life.”

Instruction includes lectures from invitedexperts and reviews of the current literature onbest practices. This approach ensures that graduatesare familiar with palliative care excellence andare well positioned to contribute to the palliativecare body of knowledge. Each of the clinicalnurse specialist students also completes apracticum. Many spend hours at the ClevelandClinic’s Harry R. Horvitz Center for PalliativeMedicine where they work with the inpatientand outpatient clinical teams. “They are veryinvolved and part of the interdisciplinary team,”Sheehan explains. Students often spend time atthe Hospice of the Western Reserve’s HospiceHouse where they work with advanced practicepalliative care nurses, physicians and other pro-viders. Students also work at a variety of otherclinical sites, where they learn from professionalswho provide grief and bereavement services.

Graduates in DemandStudent and preceptor evaluations are verypositive. They are used to reinforce the strengthsof the curriculum and seek direction for improve-ment. Program graduates are in demand byclinical agencies and physicians. “More and morehealth care professionals nationwide are callingand asking when we will graduate the next class,”Sheehan says. “Of the seven nurses who havegraduated so far, four are directly involved in theprovision of palliative care.”

Personal ReflectionPrior to establishing this graduate program,Sheehan’s research showed that there were noprograms that incorporated palliative care inOhio or the nation. “I decided that palliative careneeded to be included in the curriculum and thatit needed to be a partnership between students,clinical agencies and faculty. The education weare providing nursing students is paving the wayto improve the ability of medical institutionsand communities to care for people with lifethreatening illnesses and their families.”

Training for the Future

Denice Kopcha Sheehan, RN, MSN

Deborah Witt Sherman, PhD, APRN, ANP, BC, FAAN

PALLIATIVE CARE NURSE PRACTITIONER PROGRAMNew York University, Division of NursingNew York, New York

Deborah Witt Sherman coordinates the firstpalliative care nurse practitioner program in thecountry. New York University’s master’s programand post-master’s certificate program preparenurse practitioners to provide comprehensiveand compassionate care to individuals andfamilies who are living with or dying from anincurable, progressive illness.

Building on a Solid CoreThe palliative care curriculum builds upon thecore of the master’s program in nursing, whichfocuses on theory, research, critical thinking,knowledge development, health care policy andleadership. In addition to advanced science coursesin pathophysiology, pharmacotherapeutics andadvanced physical assessment, students takerole development courses and five specializedpalliative care courses, totaling 710 preceptedclinical hours. Palliative care course topicsinclude loss, grief, death and bereavement;management of pain and suffering; end-of-lifecare; symptom management; and nursingleadership in palliative care.

The program also builds upon a commontrait of nurses—a deeply rooted humanitarianconcern. “Our program allows nurses toacknowledge their human compassion as well astheir expert knowledge and advanced practiceskills in palliative nursing.” Sherman explains.“This quality is what makes the program a verydifferent experience.”

Each student receives both inpatient hospitaland hospice palliative care experience. Studentsselect where they receive this experience froma list of clinical sites that meet the student’seducational goals.

Sherman collects evaluation data at the endof each semester from each of her students.Students evaluate their courses, faculty, precep-

tors and clinical sites. Program preceptors alsoevaluate the curriculum and their students. Thisinformation is used to strengthen the curriculumand to identify program and course competencies.Since the inception of the master’s program inthe fall of 1998, 15 students have graduated andare demonstrating nursing leadership in palliativecare. Currently there are 34 master’s and post-master’s students in the program.

Making a DifferenceAs a member of the nursing faculty for a newlyfunded interdisciplinary palliative care fellowshipprogram at the Veterans Administration Hospitalin the Bronx, Sherman and her colleagues aredeveloping an interdisciplinary palliative carecurriculum for physicians and a master’s-preparedcurriculum for nurses and social workers. Theseinterdisciplinary initiatives emphasize the valueof collaborative practice in ensuring qualitypalliative care.

“As a cutting-edge specialty,” Sherman notes,“palliative care is well-suited for the advancedpractice nurse who wants to make a differencein the lives of patients and families who areliving with and dying from incurable, progressiveillness. It is an incredible opportunity to care forindividuals at a very critical time in their lives, atime when they are extremely vulnerable andneed expert nursing care. Advanced practicenurses,” she continues, “can assist patients andfamilies in achieving growth, well-being andquality of life throughout the illness trajectory,even as death approaches.”

Sherman believes that New York University’sadvanced practice program in palliative carenursing can be emulated and, in fact, must be ifpalliative care is going to be recognized as anursing specialty by state boards of nursing. Sheencourages other graduate programs in nursingto consider developing a palliative care master’sprogram, a post-master’s certificate program inpalliative care and/or a dual concentration forstudents in adult nurse practitioner or geriatricnurse practitioner programs.

Personal ReflectionSherman herself continues to follow her calling.She advises aspiring students: “Follow yourheart. The answer is inside you. If you are alwaysdrawn to people with incurable illness and feelcompelled to offer them support, that’s amessage. Listen to what your heart is saying.”

FUTURE DIRECTIONSAs these brief profiles reveal, APNs represent avaluable resource for responding to the needs ofseriously ill Americans and their families—in awide variety of geographic and clinical settingsand in difficult demographic and sociologic circumstances. All the APNs profiled here arepioneers in overcoming barriers and creatingviable and sustainable practices. The clinicalexpertise and the caring capacity of advancedpractice nurses should not go untapped as thenumber of elderly people grows and the medicalsystem attempts to care for them.

Advanced practice nursing in palliative careoffers an exciting career opportunity that canhelp attract a new generation of men andwomen to the field of nursing and the proudprofession of caring. Currently, however, APNsface challenges in training and licensure, andthey may encounter regulatory and reimbursementbarriers. With the development of generalist andadvanced practice credentialing examinations andthe creation of undergraduate and graduateadvanced practice programs in palliative carenursing, the time has come for palliative carenursing to be recognized as a specialty in allstates. With this recognition, the dream of makingeffective and compassionate care available forseriously ill and dying patients and families willbe one step closer to becoming a reality.

Conclusion

1000 East Beckwith AvenueMissoula, MT 59812406.243.6601 Phone406.243-6633 [email protected]

Promoting excellence in end–of–life careA NATIONAL PROGRAM OFFICE OF

The Robert Wood Johnson Foundation

advanced practice nursing: pioneering practices in...

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