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A number of underlying tenets are contained within the context of the NCP guidelines and are defined within the 8 domains. Successful exhibition of the elements within each domain has streamlined our services and has provided insight for self-assessment and quality improvement. How these elements are demonstrated within each domain will be discussed in brief.
Domain 1: Structure and Process of Care focuses on the composition, training, education, of the IDT, which must provide coordinated assessments. According to the NCP guidelines, PC is best delivered by an IDT composed of the following disciplines: Physician, Nursing, SW, and Chaplain. Domain 1 also emphasizes quality assessment processes and improvements. Coordinated assessments and documentation are displayed through the development and use of discipline-specific PC note templates that are utilized within the Electronic Medical Record (EMR), which mirror one another. Substantiating PC-specific education is easily accomplished when IDT members are PC-certified within their respective discipline. All of our physicians are board certified for PC, our adult SWs are certified in hospice and PC SW and our NPs have recently completed the PC certification review course for APRNs with the intent to test in the near future. Although ineligible for certification in chaplaincy and PC, our chaplain residents have received ongoing education and training specific to PC. Annually, we conduct a least one quality improvement project augmenting the quality of services provided. We have participated in a number of research studies and members of our team have even served as the principal investigator in some. Finally, a number of national and international presentations have been done by members of our team.
Domain 2: Physical Aspects of Care highlights the assessment and treatment of distressing physical symptoms. Interventions delivered within our PCS are multifactorial and include interventions that are pharmacologic, non-pharmacologic such as aromatherapy and consultations for osteopathic manipulative medicine, interventional, and those that have a curative intent. We have also developed and utilize order sets within the EMR; members of our team attend weekly ICU multidisciplinary rounds; and our neonatal team attends the weekly “What’s to Come” meeting that discusses high-risk obstetric patients within our community.
Domain 3: Psychological and Psychiatric Aspects focus on the collaborative assessment process regarding the aforementioned concepts. Collaboration with the family and the IDT is inherent to PC and this has been measured by our team by way of a core measurement for our TJC certification. Our team determined the percentage of family conferences that were multidisciplinary, establishing a goal, and included both elements. Furthermore, this domain now features needed elements required for a bereavement program, which is provided through our Pastoral Care Department. Our facility also employs Phoebe, our Canine Comfort companion who visits our facility each Monday but will make special visits when someone is in need.
Domain 4: Social Aspects of Care emphasizes the IDT execution of assessments to identify, support, and exploit patient and family strengths. PC referrals may be initiated by anyone within our facility who identifies PC needs and weeCARE, our neonatal PCS, is offered at any point during an infant’s life, including inutero. PCS is also vastly immersed and involved within our community.
Domain 5: Spiritual, Religious, and Existential Aspects of Care defines spirituality and stresses the IDT’s ability to tend to spiritual concerns throughout the illness, honing in on the expertise of an appropriately trained chaplain to explore, assess, and tend to identified needs within this realm. Shortly after achieving our initial certification, our PC chaplain unexpectedly died, leaving heavy hearts and a void to fill within our team. An attempt to find a hospital staff chaplain dedicated to our PC population was trialed however; our average monthly census approximates 200 patients. An initial in-depth spiritual/religious/existential assessment by a PC chaplain is required by TJC for all PC patients, which proved to be an unfeasible expectation for one person. To accomplish this seemingly insurmountable feat, we sought an alternative approach and broached the subject of partnering with our clinical pastoral education (CPE) department. The CPE directors and the PC leadership team composed an 8-week didactic curriculum differentiating and encompassing specific elements inherent to PC chaplaincy. This didactic was taught by both the CPE directors and the PC leadership teams and this was followed by 8-weeks of case presentations, laying the foundation of our new CPE-PC education model.
Domain 6: Cultural Aspects of Care exploits culture as a source of resilience and strength for patients and families. We have identified an invisible population in our adult facility, the children of those who are hospitalized and recently we have added a child life specialist to our IDT whose training has prepared her to meet the needs of this once invisible population. A number of other methods are also utilized to validate this domain.
Domain 7: Care of the Patient at the End of Life underscores the communication and documentation of the signs and symptoms of the dying process and further accentuates meticulous pain and non-pain assessments and interventions. Life Transitions is an informative booklet provided to families that describes the signs and symptoms of impending death. It is written in lay terms and is available in both English and Spanish. A butterfly magnet and a leaf with a drop of water are simple non-verbal symbols utilized within our institution. These non-verbally alert staff not directly involved in the patient’s care that this patient is imminently dying and that any interaction should proceed with discretion.
Domain 8: Ethical and Legal Aspects of Care highlights the importance of the IDT in advanced care planning through ongoing discussion regarding goals of care and execution of Advance Directives. Encountering ethical dilemmas is commonplace and the PCS seeks the expertise of our hospital’s ethicist, who also plays a pivotal role as a member of our PC Steering Committee. The IDT acknowledges and addresses any legal concerns, which can be encountered in situations of futility and withholding and withdrawing life-sustaining medical interventions (ventilator support, dialysis, vasopressors, etc). A note template in the EMR is utilized when a patient or family has chosen to withdraw life-sustaining interventions. Our most recent venture has been in the development of our neonatal Donation after Cardiac Death protocol.
The PCS within our facility is a robust program that is comprehensive and focuses to enhance communication, provide family support and education, facilitate healthy coping, assist with ethical dilemmas, and establish realistic goals of care. A number of obstacles were encountered as we ascended to our first successful recertification. Hospital-wide staff education and preparation was and continues to be a challenge we encounter. A number of methods have been employed to continually educate more than 3,300 hospital clinical staff and nearly 1,200 hospital privileged physicians within our institution. Dependency on our PC Champion Committee, which is comprised of a representative from each of the inpatient units and departments within the hospital, is pivotal. The Champions meet monthly and take information back to their respective units to help define PC, differentiate between PC and hospice, and help identify appropriate patients in their unit that would reap benefits from PCS.