Providing Quality Palliative Care: Policy Improvement

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Introduction

The vague language of the current Intermountain Healthcare (IH) description of PC results in insufficient elaboration of specific nursing responsibilities such as quality of patient life, caregiver support, and non-discriminant patient treatment. A comprehensive PC policy has not been adopted in the IH facilities, leaving care teams to devise an individual approach to each terminal patient, which may be inefficient and result in subpar service. Across the country, many HCPs lack knowledge and skills in pain and symptom management, communication, and care coordination, while the public has only a vague understanding of the benefits of PC and how to access them (Meier et al., 2017). Given a wide range of responsibilities in providing palliative care (PC) and lack of specific instructions, IH healthcare providers (HCPs) filling only primary orders such as medical prescriptions may coincidentally neglect some care aspects. Therefore, an instructive PC policy is needed to facilitate successful administration and ensure equitable access to care services in the IH facilities.

Current Policy

Due to the lack of an established PC policy, most details were obtained from annual reports and public website sections. Palliative care in IH facilities pursues several goals: quality of patient life, symptom relief, family and caregiver support, and a team approach to care and care aligned with patients’ aspirations (Intermountain Healthcare, 2018). However, the current key goal is for HCPs to focus on managing pain and other symptoms like nausea or sleep problems (Intermountain Healthcare, 2020b). None of the listed elements are thoroughly elaborated, including the key goal. Intermountain Healthcare (2022) nursing services for end-of-life care include symptom assessment, “skilled services and treatments,” and situational management. In addition to nursing care, patients and their families can expect the care team to cover counseling, emotional and spiritual support, medication and supplies, domestic helper services, and home care in acute need (Intermountain Healthcare, 2022). The nuances are to be addressed in a plan of care (POC), jointly created by the care team and the patient based on the diagnosis, symptoms, and other needs (Intermountain Healthcare, 2022). However, it is unclear what ‘skilled services’ constitute or how detailed POCs are.

Literature Review

Scholars in medical and legal research encourage the development of detailed palliative care policies. Supporting this initiative, IH developed a hospital-based electronic palliative care algorithm to improve the identification of patients benefitting from PC services and calculate PC penetration rates (Gruhler et al., 2018). The algorithm then indicated that the need for receiving PC might be as high as 26.4% of the total IH inpatient population (Gruhler et al., 2018). It will be progressively more challenging for HCPs to devise individualized care plans for IH patients with as high and potentially increasing numbers. Therefore, an approach with great universal applicability is needed to meet this demand.

Furthermore, the policy focus should be on restructuring service delivery as a whole. Palmryd et al. (2021) found that nurses caring for intensive care unit patients did not prioritize integrity, arguing that more explicit guidelines are required to ameliorate the issue. This issue may apply to the IH facilities, given that extant IH guidance on PC does not identify the expectations and responsibilities of each party. Thus, the research mandates a policy change to guide productive communication between providers and patients.

Additionally, the lack of a universal, comprehensive PC opens a leeway for bias. A striking finding was that patients’ quality of end-of-life care might depend on the disease the patient suffers (Martinsson et al., 2018). At the same time, Spraker-Perlman et al. (2019) found that IH patients without known critical conditions (CC) benefit significantly from PC support before their death just as much as patients without CC. Therefore, the research necessitates ensuring that the non-discriminant approach to PC provision is specified in the policy.

Lastly, blaming IH nurses for negligence is impractical, given their inability to assist sometimes. The outbreak of the COVID-19 pandemic has demonstrated that the lack of resources and nursing burnout contribute to the increased negligence in PC (Human Rights Watch, 2021). In its Annual Report (2020a), IH recognized that its caregivers focused on creating personal protective equipment (PPE) assembly lines, with their regular duties seeing a significant decrease in hours because of the pandemic. This situation mandates ensuring that nurses can meet the care requirements. Hence, the policy to improve patient care should involve reconsidering the carer support system, as nurses’ workload can interfere with the quality and quantity of services provided.

Discussion Outline

A detailed assessment of contributing factors, strategic goals, and budget plan will be required to create and implement the policy successfully. The policy should ensure even responsibility distribution and uphold an appropriate accountability standard for non-compliance. It should provide an appropriate level of detail in each aspect and implement enforcement mechanisms to avoid regular duties suffering due to negligence. Moreover, sufficient staffing in every establishment is mandatory to avoid situations where IH staff is overwhelmed with double duty. Overall, the proposed approach should create concrete and explicit guidelines regulating nursing staff responsibilities in end-of-life care, a comprehensive support network for HCPs and patients, and specific instances of accountability.

Demographics

The COVID-19 pandemic highlighted that curative care is currently at the core of provider-patient interaction over any PC aspect. During an acute crisis, hundreds of IH staff members were sent to help in New York hospitals (Intermountain Healthcare, 2020a). The crisis may have passed, but the question of which duties take priority remains, which may be overwhelming for the IH facilities staff. Therefore, the major demographic that policy changes can affect will be nursing staff needing explicit guidance on responsibilities and expectations. Further, the inpatient population of the IH facilities will be experiencing the consequences of the changed PC routine.

Morbidity and Mortality Rates

Not addressing the issue of inadequate PC may impact mortality rates significantly. Gruhler et al. (2018) estimate 90 million Americans currently living with serious, life-threatening illnesses and expect the number to double within 25 years. There is strong evidence of PC reducing acute unplanned hospitalizations and specialized PC services associated with improved short- and long-term care outcomes (Sleeman et al., 2021). Therefore, improving the policy approach to specialist palliative care would improve patient outcomes.

Disparities Resulting from the Current Policy

The poorly recognized role of end-of-life care in current policy contributes to unequal access to care. Although PC is increasingly recognized as a human right, the lack of guidelines’ support and research prevents many from utilizing it (Sleeman et al., 2021). Specifically, there are two downsides resulting from IH policy reliance on the individual POCs in the facilitation of end-of-life and palliative care. First, individualized POCs mean no universal standard of conduct is established; coupled with a potentially limited level of patient understanding of the services they may require, this could result in underperformance. Second, Intermountain Healthcare’s (2022) policy states that the hospice program and the patient’s physician must approve any proposed POC tests, procedures, and services, adding that “generally, treatments necessary for symptom or pain management” are approved. Therefore, services beyond the necessary symptom management may not be approved.

Cultural Issues

The proposed change in policy would provide an all-encompassing transformation of the extant system. If any of the PC aspects in IH are currently dependent on creating individualized POCs, these aspects will be thoroughly regulated in the future system. For the IH care teams that are used to working closely with each patient, such a system may initially seem overly prescriptive. Additionally, the cultural background may influence patients’ decision-making regarding pain and PC, making it vital to consider the patient’s beliefs regarding care and death before forming an all-encompassing instructive guidance of staff conduct.

Readiness for Change and Stakeholders

America has seen tremendous growth in palliative care in the 21st century, indicating the national readiness for policy change and implementation. The IH facilities are receptive to innovative missions and have supported designing other healthcare policies, such as Primary Promise – IH’s plan to build children’s national model health system (Intermountain Healthcare, 2020a). Providers and policymakers have begun recognizing the potential benefits of PC for patients with severe illness at any stage (May et al., 2021). The major stakeholders are HCPs and terminally ill patients in IH facilities, both groups being receptive to potential policy changes.

Costs

The costs of implementing a PC health policy have been scarcely investigated in recent years. Increasingly, though still limited, evidence supports the efficacy and cost-effectiveness of specialized PC (Sleeman et al., 2021; May et al., 2021). Patients who receive early specialized PC show improvements in a range of outcomes, including physical symptom control, survival, and quality of life, and caregivers report increased satisfaction and decreased depression (Sleeman et al., 2021). Moreover, appropriate and timely provision of PC likely lowers overall healthcare expenses (May et al., 2021). Therefore, the costs of keeping current HCPs and effectively helping patients in IH facilities may be reduced by implementing a new policy.

References

Annual report 2020. (2020a). Intermountain Healthcare. Web.

Eligibility and coverage: End-of-life care. (2022). Intermountain Healthcare. Web.

Gruhler, H., Krutka, A., Luetke-Stahlman, H., & Gardner, E. (2018). Determining palliative care penetration rates in the acute care setting.Journal of Pain and Symptom Management, 55(2), 226–235. Web.

Martinsson, L., Lundstrom, S., & Sundelof, J. (2018). Quality of end-of-life care in patients with dementia compared to patients with cancer: A population-based register study.PLoS ONE, 13(7), e0201051–e0201051. Web.

May, P., Tysinger, B., Morrison, S., & Jacobson, M. (2021). Advancing the economics of palliative care: The value to individuals and families, organizations, and society. USC Schaeffer Center White Papers. Web.

Meier, D. E., Back, A. L., Berman, A., Block, S. D., Corrigan, J. M., & Morrison, R. S. (2017). A national strategy for palliative care.Health Affairs, 36(7), 1265–1273. Web.

Palliative care (Fact sheet for patients and families No. FS239-04/20). (2020b). Intermountain Healthcare. Web.

Palmryd, L., Rejnö, Å., & Godskesen, T. E. (2021). Integrity at end of life in the intensive care unit: A qualitative study of nurses’ views.Annals of Intensive Care, 11(1), 23. Web.

Sleeman, K. E., Timms, A., Gillam, J., Anderson, J. E., Harding, R., Sampson, E. L., & Evans, C. J. (2021). Priorities and opportunities for palliative and end of life care in United Kingdom health policies: A national documentary analysis.BMC Palliative Care, 20(1), 108. Web.

Spraker-Perlman, H. L., Tam, R. P., Bardsley, T., Wilkes, J., Farley, L., Moore, D., Sheetz, J., & Baker, J. N. (2019). The impact of pediatric palliative care involvement in the care of critically ill patients without complex chronic conditions.Journal of Palliative Medicine, 22(5), jpm.2018.0469. Web.

Supportive/Palliative Care. (2018). Intermountain Healthcare. Web.

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