The CINAHL, MEDLINE, Pubmed, OVID, and ProQuest databases were searched using the key terms of palliative care, advanced care planning, and advance directives. Inclusion criteria were English-language studies published between 2008-2017, adult population, and research sites in the United States. This search strategy identified 546 publications of which 17 were selected that included nine descriptive studies, six quasi-experimental studies or randomized control trials, and two observational cohort studies with a mixed methods design.
The literature findings suggest that chronically-ill patients spend much of their time either preventing a crisis, dealing with a crisis, or recovering from a crisis (Karasouli et al., 2016; Wachterman et al., 2017). Both potential or actual crises require a nursing intervention by home health care nurses in the home, nurse practitioners in the clinic or office, and/or acute care nurses in the hospital’s emergency department. Thus, a conceptual model was developed that integrated palliative care along the chronic illness continuum with crisis at its center. The model describes three phases of palliative care: early palliative care between stability and crisis, episodic palliative care during a crisis to improve the patient’s well-being and prevent a recurrence of the crisis, and late palliative care between crisis and hospice care prior to death.
Early palliative care was provided to medically-stable patients with interventions that included discussions with healthcare providers and community education regarding topics focused on advanced care planning. Study participants reported greater preparedness to make future self-care decisions, and knowledge of advance directives (e.g., do not resuscitate orders and healthcare proxies) that promoted confidence when completing advanced directive forms (Huang et al., 2016; Lee, Hinder, & Friedmann, 2015; Sun et al., 2017). Episodic palliative care interventions focused on patients experiencing a hospitalization related to their disease process. Inpatient interventions included palliative care screening, consultation, and clinical discussions that resulted in patients completing the advanced directive documentation. The findings indicated that patients receiving an inpatient palliative care consultation had shorter lengths of stay in the hospital and were less likely to die in an acute care setting (Zalenski et al., 2014; Zalenski et al., 2017; Rocque et al., 2017). Late palliative care targeted terminally-ill patients having an advanced disease process. Interventions included palliative care consultation, clinical discussions, and provider-focused education that focused on the immediate completion of advanced directives, pain management, hospice care, and length of stay. The findings indicated that patients engaging in palliative care discussions with their provider or seen by a palliative care service were more likely to have documented advanced directives and discharged home to hospice care (Sharma et al., 2015; Shen et al., 2016).
This innovative, evidence-based conceptual model integrated the various timings, components, and clinical outcomes of palliative care utilization found in the literature. Thus, this conceptual model is intended to guide future palliative care nursing research that holistically captures and assimilates the patient, family, and caregiver perspectives of the chronic illness experience. Palliative care provides an avenue in which the patients can navigate through their chronic illness experience armed with a confident voice to ensure their wants and desires are communicated to healthcare providers. The best time for nursing interventions is during early palliative care to prevent crises from occurring during the patient’s chronic illness experience, but research is needed to test this notion. Moreover, research is also needed to determine the most effective nursing interventions for preventing crises.
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