NURSING ASSIGNMENT 2

rock n roll

5.Improvingend-of-lifecare-RecommendationsfromtheIOM.pdf

Home >Nursing homework help >NURSING ASSIGNMENT 2

26 The Nurse Practitioner • Vol. 41, No. 9 www.tnpj.com

By Elizabeth H. Dobbins, PhD, APRN, FNP-BC, CNE

Abstract: A 2014 consensus report by the Institute of Medicine offers

recommendations for healthcare providers to decrease unwanted care and

improve the quality of life at the end of life. This article discusses the

recommendations of interest to advanced practice registered nurses.

Improving end-of-life care Recommendations from the IOM

2.0 CONTACT HOURS

Keywords: advance directives, advanced practice registered nurses, artifi cial nutrition, dementia, end-of-life care, ethics,

evidence-based practice, hospice, palliative care, primary care

n 1997, the Institute of Medicine (IOM) pub- lished a landmark report, Approaching Death: Improving Care at the End of Life, which ad-

dressed concerns of the public regarding the poor qual- ity of life at the end of life.1 These concerns were raised because many of those dying from acute or chronic diseases in the United States were observed to experi- ence a protracted death, made possible by advances in healthcare technology. These advances include artifi cial ventilation, CPR, and artifi cial nutrition and hydra- tion. This ineffective care resulted in greater suffering for patients and increased cost to society. The authors concluded that “people should be able to expect and achieve a decent or good death—one that is free from

avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards.”1

In September 2014, an interdisciplinary committee at the IOM published an update of the state of medi- cal care for individuals with life-limiting illnesses or medical conditions who may be approaching death. The report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, reviewed the progress made since the 1997 report.2 The committee acknowledged that many opportunities still remained to improve the quality of care provided to those at the end of life.

www.tnpj.com The Nurse Practitioner • September 2016 27

Ku pi

co o

/ i St

oc k

28 The Nurse Practitioner • Vol. 41, No. 9 www.tnpj.com

Improving end-of-life care

Advanced practice registered nurses (APRNs) provide care to patients throughout the lifespan in many different settings. APRNs working in primary care, long-term-care facilities, and as hospitalists can expect to see an increase in patients age 65 and older, refl ecting the swell of baby boom- ers in the United States. As the complexity of care increases with patient age, APRNs working with aging patients will fi nd themselves increasingly challenged by a fragmented healthcare system. With those challenges, however, come great opportunities.

To most effectively and effi ciently care for these patients, the IOM recommends that care decisions be evidence-based and support the collaborative healthcare choices of patient and provider.3 Evidence-based practice guidelines have been shown to improve patient outcomes and reduce health care costs throughout the lifespan, particularly at the end of life.4

■ Delivering end-of-life care

The IOM recommends a palliative approach to patient care.2 The World Health Organization defi nes palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness via early identifi cation and impeccable assessment and treatment.5

Palliative care principles can be applied in any setting and integrated into disease-specifi c care. Many larger hospitals now offer formal palliative care programs, which include the specialized services of physicians, APRNs, and social workers.2,6

Palliative care has been shown to result in a higher qual- ity of life and increased dignity, emotional and spiritual sup- port, and patient and family well-being. Evidence suggests that patients receiving palliative and hospice care live longer when compared with similar patients who do not receive those services.7,8 The authors of a study investigating the impact of early palliative care for patients with metastatic non–small cell lung cancer found that the mean survival rate was 3 months longer for patients receiving the interven- tion.9 Another group of investigators found that clinic-based outpatient palliative care services implemented before the patient was eligible for hospice admission lived an average of 9 days longer under hospice care.10

According to the Center to Advance Palliative Care (CAPC), the prevalence of hospitals (50 or more beds) with a multidisciplinary palliative care team increased 165% from 2000 to 2013.11 In 2000, less than one-quarter of U.S. hospitals had a palliative care program; by 2013, nearly three-quarters offered palliative care services to their patients.11 Financial reimbursement to physicians and NPs who provide palliative care consultation services is available under Medicare Part B, Medicaid, and some commercial insurances.12

Patients with dementia and other debilitating chronic diseases frequently experience eating and swallowing prob- lems. It is commonly believed that such problems indicate the end of life is near as they frequently lead to life-limiting complications.13,14 Pneumonitis due to aspiration of solids and liquids was ranked 15th in leading causes of death in the United States in 2013.15 When 323 long-term-care facility residents were followed for 18 months, researchers found 86% of patients with dementia developed eating problems, which led to infection, malnutrition, and hospitalization.16

Patients with dementia and other end-stage chronic diseases often receive invasive care, which may be of lim- ited value. A recent review of the literature concluded that artifi cial nutrition did not prevent aspiration pneumonia, decrease pressure ulcers, improve functional status, reduce or prevent malnutrition, provide comfort, or reduce mor-

tality.13,17 Efforts to prevent patients from pulling out tubes also resulted in increased agitation and the use of me- chanical or chemical restraints for more than one-third of the patient sample, increasing the burden of suffering.18

Careful hand-feeding is an evi- dence-based palliative approach fore-

going caloric intake and focusing on patient comfort. Many professional organizations support this feeding technique, including the National Hospice and Palliative Care Or- ganization (NHPCO), American Board of Internal Medi- cine, American Geriatrics Society, and Canadian Geriatrics Society.19-22

Food and fl uids can be offered as long as the patient has an interest in “recreational eating.”23 Evidence shows, however, that even if oral feedings are consistent and toler- ated, they will not improve function or cognition or de- crease the mortality for individuals with moderate-to-severe dementia.14

Hospice services extend palliative care principles to the end of life (see The continuum of palliative care). Patients are eligible for hospice care if they have a projected life expec- tancy of 6 months or less and have decided to forgo curative disease-directed therapies. In addition to a medical director, nursing staff, and social workers, hospice care providers may

Patients with dementia and other

debilitating chronic diseases frequently

experience eating and swallowing problems.

Improving end-of-life care

www.tnpj.com The Nurse Practitioner • September 2016 29

also include chaplains, hospice aides, dietitians, and thera- pists.24 Mirroring the growth in palliative care programs, the number of agencies offering hospice services has also grown. According to the NHPCO, of all Medicare decedents in the year 2001, 18.1% accessed hospice services for 3 or more days; by 2013, that percentage rose to 47.3% with over 1.5 million patients receiving care.25 Hospice care is funded by the Medicare Hospice Benefi t, which provides hospice- related services and supplies related to the patient’s care.2,26

■ Clinician-patient communication and

advance care planning

The IOM emphasizes that all individuals should have the op- portunity to actively participate in their healthcare decisions throughout their lives.2 Advance directives (living wills and durable powers of attorney for healthcare) provide a means for patients to communicate to their healthcare providers what they want for themselves at the end of their lives. This information is especially important for cases in which pa- tients are unable to speak for themselves.

Included in advance care planning, but not intended as a replacement for advance directives, the Physician Orders for Life-Sustaining Treatment (POLST) are medical or- ders written for patients with serious illnesses who may die within the next year. Intended to stay with the patient across care settings to prevent unwanted emergency interventions, the form is prepared by the patient’s healthcare provider and documents the patient’s preferences with respect to treatment and preferred site for receiving care and death. Although variations of the form are used in many states, the POLST may not be recognized if the patient moves into a jurisdiction that does not utilize the form, such as Alabama, Arkansas, or South Dakota.27,28

The IOM identifi es primary care providers as being in an ideal position to begin end-of-life conversations with their patients.2 Advance care planning can begin at any patient- care interaction, regardless of age or health status. Com- munication between the healthcare professional and the patient and family should be clear, open, and respectful to facilitate the development of a therapeutic relationship and negotiate and complete the advance care plan documents.2,29

The Centers for Medicare and Medicaid Services (CMS) and the American Bar Association recommend that original copies of the advance directive documents be kept where they can be easily found and that copies be provided to healthcare proxies, providers, hospitals or long-term-care facilities, family, and friends. Carrying a wallet card and re- viewing the documents annually are also recommended.30,31 Advance care planning has been found to be the strongest and most consistent modifi able factor that can help patients avoid unwanted or unnecessary treatments.14 Nonetheless,

researchers continue to fi nd that most individuals in the United States have not prepared these documents.

Historically, communication between clinicians and pa- tients has been poor, particularly when discussing prognoses and concerns in cases of serious advanced illnesses.2 Accord- ing to Bernacki and Block, physicians surveyed regarding this blamed time constraints, personal discomfort in dis- cussing end-of-life issues, lack of training in communicating those issues, and uncertainty about prognosis accuracy.32

Reasons reported for patients not completing advance directive documents included a lack of awareness, not want- ing to think about death or dying, not realizing they had a terminal disease, or waiting for the provider to initiate the conversation.2,33 Additional reasons that patients did not complete advance directives were not knowing about ad- vance care planning, being too young, and having concerns about the process being too costly.34

The IOM recommends that primary care providers initi- ate advance care planning discussions long before a medical crisis is expected.2 Patients with dementia or other cognitive disorders pose challenges to providers of end-of-life care, as capacity to understand, retain, and evaluate information can be diffi cult to assess.35

To have capacity, individuals must understand informa- tion related to the decision, retain the information, be able to evaluate the risks and benefi ts of the information, and communicate their decision.36 In the absence of advance directives, patients who have lost capacity to make decisions (patients with dementia) default to family members who may be unable or unwilling to speak on their behalf.29 Therefore, it is imperative that the discussion of patient preferences begins as early as possible in the course of the disease and be updated on an ongoing basis.

■ Professional education and development

Although exposure to palliative care content in medical, nursing, social work, and chaplaincy programs has increased

The continuum of palliative care

Diagnosis Time

Death and

bereavement

Palliative care

H o s

i c e

c a r e

Disease-directed therapies

30 The Nurse Practitioner • Vol. 41, No. 9 www.tnpj.com

Improving end-of-life care

over the past decade, the amount of time allocated to formal study remains limited. Medical schools, on average, offer only 17 hours of end-of-life care content during the 4 years of medical education.2,37 Baccalaureate nursing programs offer less than 15 hours.2 A survey of 714 practicing oncology nurses found that 25% did not believe they were suffi ciently prepared to care for a dying patient, suggesting inadequate continuing-education opportunities.38

The IOM cites the limited number of palliative care spe- cialists as a major defi ciency in access to quality end-of-life care. The American Board of Medical Specialists approved the subspecialty of Hospice and Palliative Medicine, but the number of trained specialists remains small. Although there are nearly 100 hospice and palliative medicine fellow- ship programs in the United States, there were only 6,356 physicians representing 10 medical practice areas who were board-certifi ed in hospice and palliative medicine in 2014.2 Given the expected swell in the number of patients over age

65, an estimated shortage of 6,000 to 18,000 hospice and palliative medicine specialists is predicted.39

The IOM recommends continuing-education oppor- tunities in palliative care for all healthcare professionals working with patients at the end of life.2 A number of organi- zations now provide end-of-life information and training op- portunities in a variety of formats (see End-of-life resources).

The American Association of Colleges of Nursing’s (AACN) End-of-Life Nursing Education Consortium Pro- ject is dedicated to educating healthcare professionals in the principles of palliative care and uses a modular format to teach end-of-life content.40 Modules in this train-the-trainer program include palliative nursing care; pain and symptom management; ethical and legal issues; cultural considera- tions; communication; loss, grief, and bereavement; and what to expect in the patient’s fi nal hours.

The IOM recognizes the importance of hospice and palliative nurse specialists.2 Specialization and certifi cation

End-of-life resources

Organization Description of services provided Website

American Academy of Hospice and Palliative Medicine

Offers education and practice information to

members.

Serves as an advocate for health policy change.

Nominates Fellows of the American Academy of

Hospice and Palliative Medicine (over 300 have

been inducted).

www.aahpm.org

Center to Advance Palliative Care

Provides tools, training, and technical assistance

needed to establish and maintain a palliative care

program.

www.capc.org

End-of-Life Nursing Education Consortium

Administered by the AACN, based at the City of

Hope National Medical Center.

Live train-the-trainer program teaches palliative

care skills to nurses serving a variety of patient

populations (more than 20,100 nurses and other

healthcare professionals trained worldwide).

www.aacn.nche.edu/elnec

Education in Palliative and End-of-Life Care Project

Based at Northwestern University Feinberg School

of Medicine.

Train-the-trainer multidisciplinary program teach-

es palliative care skills to those serving in a variety

of settings using live conference and distance-

learning platforms (more than 2,000 trainers are

actively teaching).

www.epec.net

Hospice and Palliative Nurses Association

Offers continuing-education activities to members.

Offers Advanced Certifi ed Hospice and Palliative

Nurse exam through Hospice and Palliative Cre-

dentialing Center (nearly 1,000 APRNs certifi ed).

www.hpcc.advancing

expertcare.org

National Hospice and Palliative Care Organization

Offers education and training opportunities to

healthcare professionals.

Advocates for social change through their Hospice

Action Network.

www.nhpco.org

Improving end-of-life care

www.tnpj.com The Nurse Practitioner • September 2016 31

validate the experience, knowledge, and skills possessed by the certifi ed individual and communicate professionalism, competence, and a commitment to lifelong learning.41 The Hospice and Palliative Credentialing Center administers cer- tifi cation exams to healthcare providers working at different levels of care. APRNs working in palliative care settings who meet published criteria are eligible to sit for the Advanced Certifi ed Hospice and Palliative Nurse exam.

■ Policies and payment systems

The IOM recommends fi nancial and policy reform by public and private insurance and healthcare delivery programs to support high-quality end-of-life care for patients with advanced serious illnesses.2 End-of-life care is expensive: Medicare benefi t payments totaled $597 billion in 2014 or 14% of the total federal budget.42

Currently, fi nancial incentives to provide care are built into Medicare and Medicaid reimbursement guidelines, often resulting in fragmented care, which increases the risks of unwanted and unnecessary care services. The current medical model is life-promoting and life-sustaining; in an emergency situation, care providers unfamiliar with the patient often default to aggressive interventions, result- ing in unnecessary suffering and costs. Medicare fee-for- service payments give healthcare providers incentives to offer high-intensity care and high-cost services, consult multiple subspecialties, order tests and procedures, and hospitalize patients.2

Because they are frequent consum- ers of medical services, the personal ex- penses of healthcare at the end of life are out of control for many older adults. Insurance plans are often confusing, overwhelming, and do not cover the to- tal cost of medical care. In a study using data from the Health and Retirement Study, the out-of-pocket expenses for over 3,200 Medicare benefi ciaries were analyzed.43

Researchers found that total out-of-pocket expenses for the 5 years prior to death amounted to $36,688 for individu- als and $51,030 for couples in which one spouse had died. Spending for patients with Alzheimer disease was higher, averaging $66,155. For 25% of those studied, the healthcare spending exceeded their baseline total household assets.43 Evidence now suggests that a coordinated healthcare system that applies palliative care principles to patient care and facilitates appropriate admission to hospice programs has decreased hospital usage and medical costs, reduced rates of unnecessary diagnostic tests, and extended life overall.2,6,44

High hospital readmission rates among long-term-care residents also contribute to the high cost of dying. According

to the CDC, 1.4 million residents are living in 15,700 long- term-care facilities in the United States.45 Resident illness or injury often results in a transfer from the skilled nursing facility (SNF) to the hospital for acute care. When Medicare statisticians examined the circumstances surrounding pa- tient transfers, they found that 25% of transferred residents were rehospitalized within 30 days of discharge. A closer review of the circumstances leading up to the transfer re- vealed that 66% of the hospital transfers were potentially avoidable.46

Each readmission results in more tests and treatments, higher healthcare costs, and increased patient suffering. To motivate hospitals and SNFs to address the “bounce back” problem, the CMS lowered payment rates for all Medicare discharges if a hospital experiences higher-than- average readmission rates for certain diagnoses, including pneumonia and heart failure.46 This situation has led to the development of programs such as Interventions to Reduce Acute Care Transitions, which was developed to promote interaction between SNFs and hospitals, primary care phy- sicians, residents, and their families to best manage care in the long-term-care facility.46

Evidence-based care paths are used by SNF staff to rec- ognize and address symptoms as early as possible. Com- munication tools such as situation/background/assessment/ recommendation improve information transfer between levels of care and decrease the possibility of medication and treatment errors.46

Although medical care is important, social service pro- grams can make the difference between a patient remaining at home or going to a long-term-care facility. At the present time, Medicare makes no provision for 24/7 home care and support except for short periods of continuous home care provided by hospices during crisis situations.24 Caregiver “burnout,” defi ned as physical, emotional, and mental ex- haustion, is common. The Alzheimer’s Association reports that 15.5 million individuals in the United States provided unpaid care to a person with Alzheimer disease or related dementias in 2013. Sixty-five percent of caregivers were women, and 21% were age 65 and older. Fifty-nine percent of caregivers reported their emotional stress as a “good amount” or a “great deal,” particularly in areas of fi nance and family relationships.47

High hospital readmission rates among

long-term-care residents also contribute to

the high cost of dying.

32 The Nurse Practitioner • Vol. 41, No. 9 www.tnpj.com

Improving end-of-life care

Programs providing home-delivered meals, nutrition counseling, transportation, and family respite and support are grossly underfunded.2 Unfortunately, the federal gov- ernment has planned reductions in most Medicare spend- ing over the next few years, perpetuating the challenges of providing home support.25

In a recent positive step, CMS announced plans to reim- burse physicians, APRNs, and physician assistants for end-of- life conversations to encourage advance care planning. After the original discussion in 2009 ended with an uninformed re- actionary public outcry against “death panels,” refocused atten- tion resulted in the decision to offer reimbursement to providers addressing advance care planning beginning in January 2016.48

The required use of electronic health records provides the opportunity to incorporate advance planning documents into the patients’ records to improve communication of this important information between disciplines and across treatment settings.8 In addition to decreasing the likelihood of unwanted care and unnecessary cost, the use of electronic records facilitates public reporting of quality measures, out- comes, and costs of care.

The IOM recommends the use of accurate, reliable, and valid quality measures for assessing care delivery and assigns accountability to the federal government for the delivery of quality care in all federal government programs it funds or administers. The development of organizational policies and professional standards, which would be tied to reimburse- ment, is also recommended.2

■ Public engagement and education

The IOM acknowledges the need for culturally appropriate public education about end-of-life choices.2 Opportunities for education and engagement are found at the societal, community, family, and individual levels.

At the societal level, the IOM identifi es public offi cials, professional organizations, religious leaders, and commu- nity groups as bearing the greatest responsibility for bring- ing the discussion about death and dying to the population at large. These groups have the greatest potential to affect public policy changes related to the organization and fund- ing of “high-quality, compassionate, and sustainable care” in institutional and practice settings.2

Advocacy and educational activities sponsored by pro- fessional organizations, which facilitate end-of-life dis- cussions between patients, families, and caregivers have been shown to be successful. A coalition between insurance groups, consumers, healthcare professionals, and others was found to increase awareness of the value of advance care planning and resulted in an increase in document com- pletion.2,49 Honoring Choices Minnesota, a project that began in 2008 and involved eight large healthcare systems, increased the number of hospitalized individuals with ad- vance directives in their electronic medical record from 12.1% to 65.6%.50 Organizations (including the NHPCO and CAPC), insurers, private foundations, and others have also sponsored public awareness campaigns regarding what constitutes good end-of-life care and how to obtain it.

Websites for consumer information regarding advance directives

Organization Description of services provided Website

Aging with Dignity/Five Wishes Advocates for quality end-of-life care and advance care planning.

Provides free information and guid-

ance to individuals, families, and

organizations in the area of advance care

planning.

Also includes an online program to

create advance directive documents

(fee required).

https://agingwithdignity.org

National Hospice and Palliative Care Organization: Caring Info

Provides information about advance direc-

tives and instructions on how to write them.

www.caringinfo.org/i4a/pages/

index.cfm?pageid=3287

The Conversation Project Works in collaboration with the Institute of Healthcare Improvement.

Promotes end-of-life conversations and

the writing of advance care plans.

www.theconversationproject.org

The State of Tennessee Department of Health

Provides downloadable advance direc-

tives forms for residents of Tennessee,

including the POLST form.

Provides consumer information in Eng-

lish and Spanish.

www.tn.gov/health/article/

advance-directives

Improving end-of-life care

www.tnpj.com The Nurse Practitioner • September 2016 33

At the community and family level, the IOM reports a growing interest in regard to death and dying, with public discussions becoming acceptable in America’s previously death-denying society.2 Public education and engagement campaigns address concerns about end-of-life care, dis- seminate relevant information, and correct misconceptions that may impede informed decision making, public support, and reform.

On an individual level, the IOM recommends mean- ingful conversations regarding patient values, goals, and preferences of care, which can lead to advance directive completion.2 Most patients are not aware of the choices they have at the end of their lives. Healthcare providers should use the information and materials available to inform and advise their patients of possible options.51 (See Websites for consumer information regarding advance directives.)

■ Moving forward

The IOM’s Future of Nursing report identifies nurses as the ideal providers of palliative care, as it is “the essence of nursing—care and caring.”52 Nurses are recognized as skilled clinicians who interpret patient responses to diseases and treatments, advocate for holistic and effective care, facilitate relationships with other care providers, and provide biopsy- chosocial and spiritual care. APRNs serve as primary care providers, hospitalists, and administrators. They function as educators, advocates, and researchers. They are ideally positioned to improve the quality and availability of medical and social services for patients and their families, enhancing quality of life through the end of life.

APRNs and other healthcare providers caring for pa- tients at the end of life are encouraged to read the entire IOM report to learn more about improving the care of dy- ing patients. These, along with current evidence-based best practices, better prepare healthcare providers, families, and caregivers to deliver compassionate, affordable, sustainable, and high-quality care to a growing population of patients facing the end of their lives.8

REFERENCES 1. Field MJ, Cassel CK, eds. Approaching Death: Improving Care at the End of

Life. Washington, DC: National Academy Press; 1997.

2. Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. 2015. www.iom. edu/ Reports/2014/Dying-In-America-Improving-Quality-and-Honoring- Individual-Preferences-Near-the-End-of-Life.aspx.

3. Olson L, Goolsby WA, McGinnis JM. Leadership Commitments to Improve Value in Healthcare: Finding Common Ground: Workshop Summary. Wash- ington, DC: National Academy Press; 2009.

4. Melnyk BM, Fineout-Overholt E, Gallagher-Ford L, Kaplan L. The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. J Nurs Adm. 2012;42(9):410-417.

5. World Health Organization. Cancer: WHO defi nition of palliative care. 2013. www.who.int/cancer/palliative/defi nition/en.

6. Meier DE, McCormick E. Benefi ts, services, and models of subspecialty pal- liative care. UpToDate. 2015. www.uptodate.com.

7. Center to Advance Palliative Care. Press releases: CAPC statement on pallia- tive care. 2009. www.capc.org/about/press-media/press-releases/2009-9-9/ capc-statement-palliative-care.

8. Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. Key fi ndings and recommenda- tions. 2014. www.nationalacademies.org/hmd/~/media/Files/Report%20 Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf.

9. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363(8):733-742.

10. Scheffey C, Kestenbaum MG, Wachterman MW, et al. Clinic-based outpa- tient palliative care before hospice is associated with longer hospice length of service. J Pain Symptom Manage. 2014:48(4):532-539.

11. Center to Advance Palliative Care. Press releases: palliative care continues its annual growth trend, according to latest Center to Advance Palliative Care analysis. 2015. www.capc.org/about/press-media/press-releases/2015-5-27/ growth-palliative-care-us-hospitals-2015-snapshot.

12. Center to Advance Palliative Care. Palliative care billing. www.capc.org/ topics/palliative-care-billing.

13. Barber J, Murphy K. Challenges that specialist palliative care nurses en- counter when caring for patients with advanced dementia. Int J Palliat Nurs. 2011;17(12):587-591.

14. Mitchell SL. Palliative care of patients with advanced dementia. UpToDate. 2016. www.uptodate.com.

15. Centers for Disease Control and Prevention. Deaths: fi nal data for 2013. www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf.

16. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced demen- tia. N Engl J Med. 2009;361(16):1529-1538.

17. Candy B, Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: fi ndings from a Cochrane systematic review. Int J Palliat Nurs. 2009;15(8):396-404.

18. Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012;172(9):697-701.

19. National Hospice and Palliative Care Organization. Commentary and posi- tion statement on artifi cial nutrition and hydration. 2010. www.nhpco.org/ sites/default/fi les/public/ANH_Statement_Commentary.pdf.

20. American Board of Internal Medicine Foundation. Feeding tubes for people with Alzeimer’s: when you need them —and when you don’t. 2013. www.choos ingwisely.org/patient-resources/feeding-tubes-for-people-with-alzheimers.

21. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014;62(8): 1590-1593.

22. Lam RE, Lam PJ. Nutrition in dementia. CMAJ. 2014;186(17):1319.

23. Long CO. Palliative care for advanced dementia. J Gerontol Nurs. 2009; 35(11):19-24.

24. Centers for Medicare and Medicaid Services. State pperations manual: appendix M—guidance to surveyors: hospice. 2015. www.cms.gov/ Regulations- and-Guidance/Guidance/Manuals/downloads/som107ap_m_ hospice.pdf.

25. National Hospice and Palliative Care Organization. NHPCO’s facts and fi gures: hospice care in America. 2014. www.nhpco.org/sites/default/fi les/ public/Statistics_Research/2014_Facts_Figures.pdf.

26. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare hospice benefi t. 2016. www.medicare.gov/Pubs/ pdf/02154.pdf.

27. POLST. Programs in your state. www.polst.org/programs-in-your-state.

28. National POLST Paradigm Task Force. POLST legislative guide. 2014. www. polst.org/wp-content/uploads/2014/02/2014-02-20-POLST-Legislative- Guide-FINAL.pdf.

29. Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. 2014. www.iom.edu/~/media/ Files/Report%20Files/2014/EOL/Report%20Brief.pdf.

30. Centers for Medicare and Medicaid Services. Medicare.gov: advance directives and long-term care. www.medicare.gov/manage-your-health/advance- directives/advance-directives-and-long-term-care.html.

31. American Bar Association Commission on Law and Aging. Tool #8: What to do after signing your health care advance directives. www.americanbar.org/ content/dam/aba/migrated/aging/toolkit/tool8.authcheckdam.pdf.

34 The Nurse Practitioner • Vol. 41, No. 9 www.tnpj.com

Improving end-of-life care

32. Bernacki RE, Block SD, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a re- view and synthesis of best practices. JAMA Intern Med. 2014;174(12): 1994-2003.

33. Rao JK, Anderson LA, Lin FC, Laux JP. Completion of advance directives among U.S. consumers. Am J Prev Med. 2014;46(1):65-70.

34. Morhaim DK, Pollack KM. End-of-life care issues: a personal, economic, public policy, and public health crisis. Am J Public Health. 2013;103(6): e8-e10.

35. Dempsey D. Advance care planning for people with dementia: benefi ts and challenges. Int J Palliat Nurs. 2013;19(5):227-234.

36. Parker M, Power D. Management of swallowing diffi culties in people with advanced dementia. Nurs Older People. 2013;25(2):26-31.

37. Dickinson GE. Thirty-fi ve years of end-of-life issues in US medical schools. Am J Hosp Palliat Care. 2011;28(6):412-417.

38. White KR, Coyne PJ. Nurses’ perceptions of educational gaps in delivering end-of-life care. Oncol Nurs Forum. 2011;38(6):711-717.

39. Lupu D, American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.

40. American Colleges of Nursing End-of-Life Nursing Education Consortium. ELNEC fact sheet. 2016. www.aacn.nche.edu/elnec/about/fact-sheet.

41. American Nurses Credentialing Center. Why ANCC certifi cation? www. nursecredentialing.org/Certifi cation/Certifi ed-Nurses-Day/Overview/ WhyCertifi cation.

42. The Henry J. Kaiser Foundation. The facts on Medicare spending and fi nancing. 2016. http://kff.org/medicare/fact-sheet/medicare-spending-and- fi nancing-fact-sheet.

43. Kelley AS, McGarry K, Fahle S, Marshall SM, Du Q, Skinner JS. Out- of-pocket spending in the last fi ve years of life. J Gen Intern Med. 2013;28(2):304-309.

44. Zahradnik EK, Grossman H. Palliative care as a primary therapeu- tic approach in advanced dementia: a narrative review. Clin Ther. 2014;36(11):1512-1517.

45. Centers for Disease Control and Prevention. FastStats: nursing home care. 2015. www.cdc.gov/nchs/fastats/alzheimers.htm.

46. HFMA Learning Solutions. Nursing homes and hospitals INTERACT to reduce hospital readmissions. Leadership. www.hfma.org/Leadership/E- Bulletins/2012/July/Nursing_Homes_and_Hospitals_INTERACT_to_Re- duce_Readmissions.

47. Alzheimer’s Association. 2014 Alzheimer’s Disease: facts and fi gures. www. alz.org/downloads/facts_fi gures_2014.pdf.

48. Belluck P. Medicare plans to pay doctors for counseling on end of life. The New York Times. 2015. www.nytimes.com/2015/07/09/health/medicare- proposes-paying-doctors-for-end-of-life-counseling.html?_r=0.

49. Compassion and Support. Community conversations on compassionate care. www.compassionandsupport.org/index.php/for_patients_families/ advance_care_planning/community_conversations.

50. Wilson KS, Kottke TE, Schettle S. Honoring choices Minnesota: preliminary data from a community-wide advance care planning model. J Am Geriatr Soc. 2014;62(12):2420-2425.

51. State of Tennessee, Department of Health. Advance directives. http://tn.gov/ health/article/advance-directives.

52. Prevost S, Rushton CH, Chrastek J, Kirschling J. Transformational models of nursing across different care settings: palliative and end-of-life care transformational models of nursing across settings. In: The Future of Nurs- ing: Leading Change, Advancing Health. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Washington, DC: National Academies Press; 2011.

Elizabeth H. Dobbins is a professor of nursing at Walters State Community Col- lege, Morristown, Tenn.

The author and planners have disclosed that they have no fi nancial relationships related to this article.

DOI: 10.1097/01.NPR.0000490388.58851.e0

For more than 192 additional continuing education articles related to Advanced Nursing Practice topics, go to NursingCenter.com/CE.

INSTRUCTIONS

Improving end-of-life care

Earn CE credit online: Go to www.nursingcenter.com/CE/NP and receive a certifi cate within minutes.

DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test.

• We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter.com. Call 1-800-787-8985 for details.

PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of The Nurse Practitioner

journal, will award 2.0 contact hours for this continuing nursing

education activity.

Lippincott Williams & Wilkins is accredited as a provider of continuing

nursing edu cation by the American Nurses Credentialing Center’s

Commission on Accreditation.

This activity is also provider approved by the California

Board of Registered Nursing, Provider Number CEP 11749 for 2.0

contact hours. Lippincott Williams & Wilkins is also an approved

provider of continuing nursing education by the District of Columbia,

Georgia, and Florida CE Broker #50-1223.

Your certifi cate is valid in all states.

TEST INSTRUCTIONS • To take the test online, go to our secure website at www.nursingcenter.com/ce/NP. • On the print form, record your answers in the test answer section of the CE enrollment form on page 35.

Each question has only one correct answer. You may

make copies of these forms.

• Complete the registration information and course evaluation. Mail the completed form and registra-

tion fee of $21.95 to: Lippincott Williams & Wilkins,

CE Group, 74 Brick Blvd., Bldg. 4, Suite 206, Brick, NJ

08723. We will mail your certifi cate in 4 to 6 weeks.

For faster service, include a fax number and

we will fax your certifi cate within 2 business days of

receiving your enrollment form.

• You will receive your CE certifi cate of earned con- tact hours and an answer key to review your results.

There is no minimum passing grade.

• Registration deadline is September 30, 2018