倡导者呼吁护士在姑息治疗中发挥主导作用
Leading nurses agree. “The essence of palliative care is embodied in nursing care,” said Cynda Rushton, PhD, RN, FAAN, professor of nursing and pediatrics at Johns Hopkins University and an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2006-2009).
Nursing, like palliative care, focuses on pain and symptom management, patient advocacy and education of the patient and family. Both fields emphasize holistic care of the patient’s body, mind and spirit; serve family members and caregivers, rather than just the patient; and take patient wishes into account when designing plans of care, according to Todd Hultman, PhD, APRN-BC, ACHP. Hultman is a nurse practitioner in palliative care service at Massachusetts General Hospital and past president of the Hospice and Palliative Nurses Association.
In palliative care, nurses are full partners with providers from other disciplines and play central roles on care teams. Palliative care teams, by definition, must include a physician, a nurse and a social worker, and often include spiritual leaders and professionals from other fields as well.
As such, palliative care is a model of interprofessional collaboration in health care, which has been linked to improved patient outcomes, more efficient use of resources, and increased retention of nurses, according to the IOM report. “As the delivery of care becomes more complex across a wide range of settings, and the need to coordinate care among multiple providers becomes ever more important, developing well-functioning teams becomes a crucial objective throughout the health care system,” the report states.
Synchronicity Between Nursing and Palliative Care
The synchronicity between nursing and palliative care is no accident. Palliative care grew out of the hospice movement of the 1960s, which was led by Cicely Saunders, a nurse and social worker in Great Britain who later became a physician. Concerned about an overall disregard for dying patients in traditional hospital settings, Saunders founded the world’s first modern hospice in 1967, and drew on her nursing background in the process.
Meanwhile, Florence Wald, RN, MSN, FAAN—the then-dean of the Yale School of Nursing—learned about and was inspired by Saunders. She opened the first hospice in the United States in 1971. Hospice care, which has a strict focus on the end of life, contributed to the development of palliative care, which covers patients who have serious health conditions at all stages of life.
Since then the field of palliative care has blossomed, and nurses have played a critical role in its growth, Hultman said. They have conducted groundbreaking research in the field, especially in the area of psycho-social and spiritual care, which helps patients and families cope with the emotional challenges of terminal and life-limited illnesses. Another key area of nurse research has been in self-care of the clinician, which helps providers stave off “compassion fatigue.”
Nurses have also helped develop a newer branch of the field concerning pediatric patients, and they have played a vital role advocating for public policies on behalf of their patients. In the early 1980s, thanks in part to the work of nursing advocates, the federal government granted Medicare beneficiaries the right to non-curative medical and support services, Hultman said.
In 1996, RWJF launched a major initiative, investing more than $170 million over 10 years to improve care at the end of life. The effort helped advance the field of palliative care, according to a 2011 report. Improvements include an increasing focus on palliative care in medical and nursing training programs and a growing cadre of certified professionals in the field. The Foundation has also supported nurse scientists and leaders like Rushton to develop the field.
Today, two-thirds of hospitals with more than 50 beds have palliative care programs, said Jay Horton, ACHPN, FNP-BC, MPH, a palliative care nurse practitioner and educator at the Mount Sinai School of Medicine and faculty with the Center to Advance Palliative Care, which receives funding from RWJF.
Still, the field has a long way to go before it is able to meet current and future demands.
Advanced practice registered nurses (APRNs), Horton said, are needed to fill a “huge gap” between the supply of palliative care providers and demand for their services. APRNs educated and trained to carry out many of the professional responsibilities associated with palliative care can be educated more quickly, and at less expense, than physicians, he noted.
Fellowships, residencies, and federal funding programs are needed to incentivize more nurses to specialize in palliative care, Hultman added. “There’s no standard pathway for nurses to enter the field. Unless an agency is willing to train an untrained person from the beginning, it’s hard for nurse practitioners to make entry into the field.”
Experts also say nurse education programs and licensure exams should include more content on palliative care. “Every single nurse needs to have basic competencies in palliative care and to know when patients’ needs have exceeded that [and the patient needs] access to specialists,” Rushton said.
Nurses also need to take on more leadership roles in palliative care, many say. That is the goal of the Palliative Nursing Leadership Institute, a new program supported by the Hospice and Palliative Nurses Association that cultivates emerging nurse leaders in the field. “There is a huge opportunity for nurses to step up, provide leadership and make clear nursing’s unique set of contributions to people who need palliative care,” Rushton said.
" data-isabstract="false" class="cmp-text">首先是好消息:越来越多的美国人寿命更长。不太好的消息呢?许多人病情加重,患有多种慢性疾病,对姑息治疗的需求日益增长,姑息治疗的重点是减轻症状,并在严重疾病的各个阶段优化生活质量。
倡导者说,问题在于缓和医疗服务提供者的短缺。他们说,护士可以帮助填补这一空白。
护士是姑息治疗的“理想提供者”报告由护士和其他健康专家组成的委员会在2010年由医学研究所(IOM)发布的关于护理的未来的报告。“姑息治疗是一种与基本护理价值观相一致的模式,包括照顾病人及其家属,而不考虑他们的年龄、文化、社会经济地位或诊断,并参与超越时间、地点和环境的护理关系。”
顶尖护士对此表示赞同。“姑息治疗的本质体现在护理中,”辛达·拉什顿博士说,她是约翰·霍普金斯大学护理和儿科学教授,也是约翰·霍普金斯大学的校友罗伯特伍德约翰逊基金会(RWJF)执行护士研究员计划(2006-2009)。
与姑息治疗一样,护理侧重于疼痛和症状管理、患者宣传以及对患者和家属的教育。这两个领域都强调对病人身体、思想和精神的整体护理;为家庭成员和护理人员服务,而不仅仅是为患者服务;并在设计护理计划时考虑到患者的意愿,根据美国儿科医学会APRN-BC分会的托德·霍尔曼博士的说法。Hultman是马萨诸塞州总医院姑息治疗服务的执业护士,也是临终关怀和姑息护理协会的前任主席。
在姑息治疗中,护士是其他学科提供者的全面合作伙伴,在护理团队中发挥核心作用。顾名思义,姑息治疗团队必须包括一名医生、一名护士和一名社工,通常还包括精神领袖和其他领域的专业人士。
因此,根据国际移民组织的报告,姑息治疗是医疗保健领域跨专业合作的一种模式,与改善患者预后、更有效地利用资源和增加留住护士有关。报告指出:“由于在广泛的环境中提供护理变得更加复杂,并且在多个提供者之间协调护理的需要变得更加重要,因此在整个卫生保健系统中建立运作良好的团队成为一个关键目标。”
护理与姑息治疗的同步性
护理与姑息治疗的同步性并非偶然。姑息治疗起源于20世纪60年代的临终关怀运动,该运动由西西莉·桑德斯(Cicely Saunders)领导,她是英国的一名护士和社会工作者,后来成为一名医生。考虑到传统医院对临终病人的漠视,桑德斯于1967年建立了世界上第一家现代临终关怀医院,并在此过程中利用了她的护理背景。
与此同时,佛罗伦斯·沃尔德(Florence Wald),注册护士,MSN, faan——当时的耶鲁护理学院院长——了解了桑德斯,并受到了桑德斯的启发。1971年,她在美国开设了第一家临终关怀医院。临终关怀严格关注生命的终结,促进了姑息治疗的发展,姑息治疗涵盖了在生命的各个阶段有严重健康问题的病人。
Hultman说,从那时起,姑息治疗领域蓬勃发展,护士在其发展中发挥了关键作用。他们在该领域进行了开创性的研究,特别是在心理社会和精神护理领域,帮助患者和家属应对晚期和生命有限疾病的情感挑战。护士研究的另一个关键领域是临床医生的自我护理,这有助于提供者避免“同情疲劳”。
护士还帮助发展了一个与儿科患者有关的新分支,他们在代表患者倡导公共政策方面发挥了至关重要的作用。在20世纪80年代早期,部分由于护理倡导者的工作,联邦政府授予医疗保险受益人非治疗性医疗和支持服务的权利,Hultman说。
1996年,RWJF发起了一项重大倡议,在10年内投资了1.7亿多美元,以改善生命末期的护理。2011年的一份报告称,这一努力推动了姑息治疗领域的发展。改善包括在医疗和护理培训项目中越来越重视姑息治疗,以及该领域越来越多的认证专业人员。该基金会还支持护士科学家和拉什顿这样的领导者发展这一领域。
杰伊·霍顿(Jay Horton)是西奈山医学院(Mount Sinai School of Medicine)的姑息治疗执业护士和教育工作者,也是接受RWJF资助的姑息治疗推进中心(Center to Advance palliative care)的教员。他说,如今,拥有50张以上床位的医院中,有三分之二设有姑息治疗项目。
尽管如此,要满足当前和未来的需求,该领域还有很长的路要走。
霍顿说,需要高级执业注册护士(aprn)来填补姑息治疗提供者的供应和对其服务的需求之间的“巨大差距”。他指出,接受过教育和培训的APRNs可以比医生更快地接受教育,而且费用更低。
霍尔曼补充说,需要奖学金、住院医师和联邦资助计划来激励更多的护士专攻姑息治疗。“护士进入这一领域没有标准的途径。除非一家机构愿意从一开始就培训未经培训的人,否则执业护士很难进入这个领域。”
专家还表示,护士教育项目和执照考试应该包括更多关于姑息治疗的内容。拉什顿说:“每个护士都需要具备姑息治疗的基本能力,知道病人的需求何时超出了这个范围,知道病人需要找专家。”
许多人说,护士还需要在姑息治疗中发挥更多的领导作用。这是我们的目标姑息护理领导研究所这是一个由临终关怀和姑息护理协会支持的新项目,旨在培养该领域的新兴护士领袖。拉什顿说:“护士有很大的机会站出来,发挥领导作用,向需要姑息治疗的人明确护理的独特贡献。”