Supportive Voice  Vol. 7 No. 3  Summer 2001

by Krista Reyna, RN, BSN and Anita Bell, RN, M Ed

Ms. Reyna is palliative care coordinator and Anita Bell is pain resource nurse, Mercy Health Center, 4300 West Memorial, Oklahoma City, OK 73120, 1-800-800-2390. Readers may call or write for a copy of the full assessment form.

Developing a palliative care service is time consuming but very rewarding. Much of the time is spent gathering baseline data to establish a program. Then the task and decision of documentation methodology for patient care begins. One soon understands all that needs to be done and questions where to begin.

Once the proposal for our program was complete and approved by administration we began working on assessment forms. The organization had routine assessment forms that were used for every patient, so it was decided to follow those forms as an outline. First we looked at how the information was entered and what happened when the form was completed. Our hospital assessments are computerized and entered by the nurse; once entered the responses help formulate the care plan. Based on how the questions are answered, nursing diagnoses are identified. Each nursing diagnosis identified then generates nursing interventions and outcomes.

Knowing the above process the team looked closely at the questions asked on admission. What else did we need to know for palliative care? The admission forms were then taken to the interdisciplinary team which then began to fine-tune the form. For most disciplines this required reviewing the literature to help identify the questions to be asked on admission. We wanted each discipline to review the assessment form and formulate additional questions that would help prompt the palliative nurse coordinator as to when specific disciplines need to intervene in the care of the patient. This assessment form would also allow other disciplines access to basic patient information.

We have found over time that patients hate to be asked the same questions over and over. A way to avoid this was to allow information from the original assessment form to be automatically pulled in through the computer system to the palliative care assessment. Then it is up to the palliative care nurse to update changes that reflect the patient's condition when she does her assessment.

After the initial assessment is complete, a care plan is automatically generated. The palliative care plan required a completely new type of care plan for the institution since most acute care focuses on curing the patient. The palliative care team took the existing care plans and began to develop a plan of care that focused on comfort needs rather than cure. This is very important for the nursing staff on the acute units because it guides them in what is expected for the patient. As an example, instead of attempting to get the patient to walk, we may be coordinating the activities to allow rest periods or teaching the patient how to modify activities in preparation for discharge home.

The assessment also looks at how both the family and the patient "learn best," so when the education process is initiated, the most effective method is utilized. The correct teaching method is important as we start discharge preparation since so much education is required for both the family and patient. If the patient learns through looking at something as opposed to reading you would want to make sure that she/he had something to look at while you are providing education.

The assessment helps with identifying discharge planning needs. Does the patient already have equipment at home or do we need to get this set up for them? Recently, a patient and family told us that if all we accomplished was to make sure that all their needs were met prior to going home, it made this a great service. Many family members struggle with what they will need when discharged, how will they get it, and who will pay for the equipment. By dealing with those issues early in the process they are able to focus attention on their loved one and not on discharge needs.

Do they have advance directives or do we need to assist them through this process? Often people are afraid to approach the subject until the patient is close to death. Our palliative care goal is to start the process early while they still have time to think about what they want but we take great care in not forcing the issue. Sometimes all that is needed is to have the information presented and allowing time for the patient to think about what she/he wants.

The ultimate documentation piece that we added to the assessment was a spiritual assessment. This can be done by the nurse but we have requested that the chaplains from pastoral care complete the form. This establishes a baseline of information for them as well as the other staff involved in the patient's care. This was quite an advancement because the pastoral care department had never done any documentation in the computer. Over time as we have introduced additional assessment and everyone has risen to meet the challenge. We have learned from experience that we must address the spiritual issues before other symptoms can effectively be managed.

The final pieces that pull the documentation process together are our team meetings. The palliative care team meets each week to discuss patients and review their plan of care, as well as work with the information management specialist to develop a team report for each patient. This report automatically compiles information from the assessment form such as code status, patient outcomes from the care plan, and patient care notes from all disciplines involved in the patient's care. Two additional pieces of documentation are generated for our physician and pharmacist, which includes the medication regimen and recent labs. This entire report leads to an effective team meeting where all the disciplines see the patient from a holistic and patient care approach.

The process of developing the palliative care assessment form may have been time consuming initially, but now the forms require very little time to complete. We discovered early that time is a valuable resource. We have worked hard to make this process efficient with the least amount of time spent on paperwork and the maximum amount of time devoted to the patient and family.