KEY POINTS

The scope of hospice and palliative care (PC) nursing continues to evolve as the science and art of PC develop in response to changes in society, including the aging of the population, changes in the trajectory of dying, and the rise in advanced chronic illnesses as the major causes of death. In contrast to the acute, disease-focused model of nursing care, in which there is less emphasis on the individuality of the patient and the relationship between the nurse and the patient and family, PC and hospice nursing focuses on the individual (and family) and on the nurse, whose responsibility involves the active, total care of patients and their families to promote and improve their quality of life (QOL; B. R. Ferrell, Coyle, & Paice, 2015; World Health Organization [WHO], 2017). The focus of PC is on the prevention and early identification of serious, progressive, chronic, or life-threatening illness and relief of pain and other physical, psychological, or spiritual problems. PC is not an alternative to other care. It is a complementary and vital part of management that should be integrated in people with advanced illness, alongside appropriate care to reverse illness or prolong life (Faull, 2012). Although hospice nursing and PC are similar in goals and intent, B. R. Ferrell et al. (2015) have indicated that the basic difference between the two is that “hospice can best be described as a program through which palliative care is intensified as an individual moves closer to death,” whereas PC is ideally delivered to “patients living with a chronic, debilitating, and progressive disease and their families . . . throughout the course of the patients' disease and its treatment.” As patients move closer to death, they should be able to transition seamlessly into a hospice program of care (B. R. Ferrell et al., 2015, p. 4).

PC and hospice nursing reflect a holistic philosophy of care implemented across the life span in diverse health settings. PC and hospice nurses relieve suffering along the course of illness, through the death of the patient, and into the bereavement period of the family (Hospice and Palliative Nurses Association [HPNA], 2017b).

Although PC builds upon the template of hospice care, the latter is now recognized as a type of PC that is offered toward the end of life. PC is the combination of active and compassionate therapies intended to comfort and support individuals who are living with and dying from life-threatening illness. The rise in hospice programs in the United States from 1 program in 1979 to more than 6,100 programs in 2014, including 1,500 hospital-based PC programs, along with a rise in the number of patients and families served from 128,000 in 1985 to approximately 1.65 million in 2014, supports the projection of future needs for hospice/PC services (B. R. Ferrell et al., 2015; Morrison, Augustin, Souvanna, & Meier, 2011; National Hospice and Palliative Care Organization [NHPCO], 2015).

PC and hospice nursing are provided to patients and their families in a variety of care settings, including, but not limited to acute care hospital units; long-term care facilities; assisted-living facilities; inpatient, home, or residential hospices; PC clinics or ambulatory settings; private practices; and prisons. Practice settings for PC and hospice nursing are changing in response to the dynamic nature of today's healthcare environment. For example, although the majority of hospice care is provided in private residences (nursing homes, homes, and residential facilities), an increasing percentage of care is being provided in hospice inpatient facilities (21.9% in 2010 vs. 26.1% in 2011; NHPCO, 2015). Fulfilling the goals of PC and hospice nursing requires the provision of a wide range of care and services by members of an interprofessional team of experts (Munday & Charlton, 2012).

PC and hospice nurses are licensed, registered nurses who are educationally prepared and qualified for specialty practice at two levels: generalist and advanced. These levels are differentiated by educational preparation, complexity of practice, and performance of certain nursing functions. Palliative and hospice-licensed practical/vocational nurses are also educationally prepared and licensed, but at a different level of complexity in their practice. PC and hospice nursing assistants are educationally prepared through local- and state-mandated processes to meet the requirements of the specific setting in which they function. These requirements differ significantly across the United States, although hours-of-education requirements are specifically defined in the home care, hospice, and long-term care settings on a national basis. There are no licensure requirements for the nursing-assistant level of palliative and hospice caregiver.

According to an article titled “History of the Hospice Nurses Association, 1986–1996” (Amenta, 2001), the founding of the Hospice Nurses Association (HNA) occurred as follows:

Membership in the organization grew rapidly. In 1998, the word “palliative” was added to the organization's name, now known as the HPNA. By the year 2000, 2,800 nurses had joined this growing organization. With a pattern of continued growth, membership to date has reached more than 11,000 across the 45 national chapters (HPNA, 2017a). In 2014, the HPNA came together with the Hospice and Palliative Nurses Foundation (HPNF) and the Hospice and Palliative Credentialing Center (HPCC) to form a partnership with a synergized mission. The three distinct organizations form Advancing Expert Care (AEC) and share a joint mission to “advance expert care in serious illness” and a shared vision to “transform the care and culture of serious illness” (Advancing Expert Care [AEC], 2016, p. 1).

EVOLUTIONARY PERSPECTIVE OF HOSPICE AND PALLIATIVE CARE NURSING

In the early years of the specialty of PC, Billings and Block (1997) identified the following forces that increased national attention regarding PC:

These factors combined to create a dramatically increased demand for healthcare providers, including nurses, who are educated at all levels to provide expert, comprehensive palliative and hospice care.

In addition, the landmark “Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment” (SUPPORT; SUPPORT Study Investigators, 1995) highlighted an urgent need for healthcare professionals who were prepared and committed to improving the QOL of seriously ill and dying patients and their families. The findings indicated a lack of communication between patients and their providers, particularly related to end-of-life (EOL) preferences, aggressiveness of medical treatments, and a high level of reported pain by seriously ill and dying patients. The SUPPORT Study Investigators (1995) believed that improving the experience of seriously ill and dying patients requires an individual and collective commitment of healthcare providers, as well as proactive efforts at shaping the caregiving process.

In 1997, the Institute of Medicine (IOM) released a significant report entitled Approaching Death: Improving Care at the End of Life (Field & Cassel, 1997). This report identified gaps of knowledge regarding the care of the seriously ill or dying. Based on this report, Field and Cassel reiterated that “the need for consensus and action to improve care for those approaching death is growing more urgent” (p. 17). On average, Americans live longer than they did in the 19th century, with more than 70% of the population dying after the age of 65 years. According to the National Center for Health Statistics (NCHS), the average life expectancy in the United States in 2016 was 78.6 years, 76.4 years for males and 81.2 years for females (Kochanek, 2017). Over the past 100 years, the leading causes of death have changed from primarily infectious diseases to chronic illnesses experienced by an increasingly aging population. In 2014, the 10 leading causes of death were heart disease, cancer, chronic lower respiratory diseases, unintentional injuries, stroke, Alzheimer's disease, diabetes, influenza and pneumonia, kidney disease, and suicide. These 10 causes of death accounted for 74% of the 2.6 million deaths in 2014 (Xu, Murphy, Dochanek, & Arias, 2016). Although some people will die suddenly and unexpectedly, the dying process for many has been extended, with some individuals, such as those with cancer, facing a steady and fairly predictable decline, whereas others will have long periods of chronic illness punctuated by crises and increasing disability that are often fatal (Gill, Gahbauer, Han, & Allore, 2010; Lage & Crombet, 2011; Lunney, Lynn, Foley, Lipson, & Guralnik, 2003). The result is a national increase in the number of individuals who require PC.

Although hospice and PC have been delivered mainly to patients with cancer, other patients with incurable diseases are also candidates for these services, including the growing number of older adults, those suffering from chronic diseases such as cardiovascular, pulmonary, neurological, and renal disease, as well as patients with AIDS (Boland & Johnson, 2013; Haley, 2013; Mitchell, Noble, Finlay, & Nelson, 2012; NHPCO, 2015; Stiel et al., 2014). In addition, the IOM collaborated with the National Cancer Policy Board and the National Research Council to release a follow-up report called Improving Palliative Care for Cancer (Foley & Gelband, 2001), which further supported the need for changes in care of the dying. The report details the undertreatment of distressing symptoms resulting from continued deficiencies in the training of healthcare professionals.

In the report titled Crossing the Quality Chasm: A New Health System for the 21st Century (Foley & Gelband, 2001), the IOM argued that professional associations should commit to professional development and competency enhancement by developing curricula, disseminating information, and promoting practice guidelines and standards related to hospice and PC. In April 2004, the standards and guidelines of PC were defined by the National Consensus Project (NCP) Steering Committee in its Clinical Practice Guidelines for Quality Palliative Care. This document was the culmination of 2 years of collaboration by 20 representatives from five leading national hospice and PC organizations, specifically the American Academy of Hospice and Palliative Medicine, Center to Advance Palliative Care, HPNA, NHPCO, and the former Last Acts organization. A need for consensus had been defined by practitioners to provide credible, broad-based guidelines for practice in an effort to standardize and improve the quality of PC in the United States. That need was affirmed when, in the first 2 weeks following publication, 90,000 copies of the guidelines were downloaded from the NCP website (www.nationalconsensusproject.org). More recent, the American Society of Clinical Oncologists (ASCO; Smith et al., 2012) issued a provisional clinical opinion (PCO) calling for the seamless integration of PC into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. Although PC is frequently misconstrued as synonymous with EOL care, PC is actually focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. The authors state that “although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services” (Smith et al., 2012, p. 1094). Strong evidence from a phase III randomized controlled trial (RCT; Temell et al., 2010, 2011) demonstrated that patients with metastatic non–small-cell lung cancer and their families significantly benefited from early PC involvement in their standard cancer care.

Based on the NCP guidelines, the National Quality Forum (NQF, 2012) released Palliative Care and End-of-Life Care in recognition of the services increasingly being rendered within the healthcare system. This report endorsed the framework of preferred practices to improve hospice and PC and has been utilized as the first step in developing quality measures (NQF, 2012). Both documents attempt to formalize the concept of PC by providing extended descriptions and definitions differentiating PC from other types of care, and each structures the theory and practice of PC into eight domains: (1) structure and processes of care; (2) physical aspects of care; (3) psychological and psychiatric aspects of care; (4) social aspects of care; (5) spiritual, religious, and existential aspects of care; (6) cultural aspects of care; (7) care of the imminently dying patient; and (8) ethical and legal aspects of care (NCP, 2013). The guidelines are for all settings in which the NQF framework has implications for reimbursement, development of quality measures, and accreditation. These documents are companion pieces serving to complement the process of improving PC quality (NCP, 2013). One of the baseline assumptions of the NCP guidelines is that the qualifications of caregivers are determined by the organizations that grant professional credentials and programmatic accreditation. As a specialty organization, the Hospice and Palliative Care Nurses Association has identified the scope and standards of hospice and PC nursing and the competencies at all levels of nursing practice, specifically nursing assistants, licensed vocational nurses, professional registered nurses, and advanced practice nurses (APNs).

EDUCATIONAL PREPARATION

It has been recognized that educational preparation for EOL care is inconsistent at best and neglected for the most part, in both undergraduate and graduate medical and nursing curricula (American Association of Colleges of Nursing [AACN], 1997; Chiu et al., 2015; Paice et al., 2006a, 2006b; Shea, Grossman, Wallace, & Lange, 2010). In addition, there is a lack of role models for students in clinical settings as well as a lack of PC content in medical and nursing textbooks (Maani-Fogelman & Bakitas, 2015, p. 30). In accordance with the International Council of Nurses' (ICN) mandate that nurses have a unique and primary responsibility for ensuring the peaceful death of patients, the American Association of Colleges of Nursing (AACN), supported by the Robert Wood Johnson Foundation, convened a roundtable of expert nurses to discuss and initiate educational change related to PC. It was concluded that precepts underlying hospice care are essential principles for all EOL care. Such precepts include the assumptions that persons are living until the moment of death; that coordinated care should be offered by a variety of professionals with attention to the physical, psychological, social, and spiritual needs of patients and their families; and that care should be sensitive to patient and family diversity. It was proposed that these precepts be foundational to the educational preparation of nurses. Based on these precepts, the document entitled Peaceful Death was developed, which outlined baccalaureate competencies for palliative and hospice care and content areas where competencies can be taught (AACN, 1997).

Emphasizing the role of nursing in EOL care, the American Nurses Association (ANA) formulated a position statement regarding the promotion of comfort and relief of pain of dying patients, reinforcing nurses' obligation to promote comfort and ensure aggressive efforts to relieve pain and suffering. Specialized PC educational initiatives began in medicine and nursing, such as Education for Physicians on End-of-Life Care (EPEC), and the nursing initiative End-of-Life Nursing Education Consortium (ELNEC). The original goal of ELNEC was to train nurse educators from associate and baccalaureate programs. The ELNEC curriculum has also been modified and specialized for graduate education, geriatrics, pediatrics, oncology, and for use with veterans.

DEVELOPING THE SCOPE, STANDARDS, AND COMPETENCIES OF PALLIATIVE AND HOSPICE NURSING PRACTICE

By developing and articulating the scope and standards of professional nursing practice, the specialty defines its boundaries, informs society about the parameters of nursing practice, and guides the development of rules and regulations for the specialty. As in all nursing specialties, PC nurses must accept professional practice accountability and ensure that their practice remains within the scope of their state's nurse practice act, their professional code of ethics, and professional practice standards.

To ensure provision of quality hospice and palliative nursing care, standards have been defined by a credible body of peers who were charged with this responsibility. The standards of hospice care were defined by the NHPCO in 1986. The standards of hospice and palliative nursing practice were first defined by the HNA in 1995, with subsequent revisions to the name of the organization to include PC. Scope and standards of hospice and palliative nursing care define the body of knowledge needed in terms of the standards of practice and performance. Standards of practice refer to the basic level of care that should be provided to all hospice and PC patients and families. Standards of performance for palliative and hospice care nurses describe the standards for activities related to quality of care, performance appraisal, education, collegiality, ethics, collaboration, participation in research, and resource utilization. Documents, such as agency standards, guidelines, policies, procedures, and protocols, may further direct the individual's performance. Standards are defined in broad terms to specify the scope of the specialty of palliative and hospice care nursing.

The standards of palliative and hospice care nursing practice are authoritative statements described by the HPNA for the nursing profession, which identifies the responsibilities for which palliative and hospice care nurses are accountable. Standards reflect the values and priorities of PC nursing and provide a framework for the evaluation of practice. The standards are written in measurable terms and define palliative and hospice care nurses' accountability to the public and the individual and family outcomes for which they are responsible. Standards remain stable over time, as they reflect the philosophical values of the profession; however, the criteria should be revised to incorporate advancements in scientific knowledge, technology, and clinical practice. Criteria must be consistent with current nursing practice and must reflect evidence-based practice.

CERTIFICATION IN HOSPICE AND PALLIATIVE CARE NURSING

Incorporated in 1987, the HNA became the first professional nursing organization dedicated to promoting excellence in the practice of hospice nursing. In March 1994, the National Board for the Certification of Hospice Nurses (NBCHN) offered the first certification examination and the credential of Certified Registered Nurse Hospice (CRNH). In 1999, the NBCHN became the National Board for Certification of Hospice and Palliative Nurses (NBCHPN), offering a new designation to recognize base competence in hospice and palliative nursing: the certified hospice and palliative nurse (CHPN). The NBCHPN is now known as the HPCC. For the licensed generalist, a minimum of 2 years of clinical experience in palliative and hospice care is recommended. By 2015, nearly 11,000 registered nurses were certified as CHPNs.

Recognizing the need to offer an examination for advanced practice hospice and palliative nurses, in 2000 the NBCHPN began discussions with New York University and the ANCC to collaborate for this purpose. In an effort to expand the portfolio of examinations, NBCHPN successfully negotiated a buy out of the partnership with ANCC effective December 2004 and has been successfully certifying nurses as advanced certified hospice and palliative nurses (ACHPNs). Eligibility for this level includes having a current unrestricted registered nurse license, graduating from an accredited institution granting graduate-level academic credit for a master's or higher degree in nursing, and having a minimum of 500 hours of supervised advanced practice in PC as a clinical nurse specialist or nurse practitioner. As of 2015, nearly 1,200 individuals were certified ACHPNs (HPNA, 2017a).

Through a commitment to a strategic plan to provide certification for all levels of caregivers, NBCHPN began certifying nursing assistants in hospice and PC in 2001 as certified hospice and palliative nursing assistants (CHPNAs). To be eligible for the examination, the nursing assistant must have a minimum of 2,000 hours in palliative and hospice care as validated by the nursing supervisor. By 2013, nearly 4,000 nursing assistants were certified as CHPNAs. Continuing with the strategy of providing certification for all levels of caregivers, in 2002 NBCHPN began the process of developing the scope, standards, and competencies for the licensed practical/vocational hospice and palliative nurse. To be eligible for the examination, the certified hospice and palliative licensed practical/vocational nurse (CHPLN) must be licensed and recommended to have logged 2,000 clinical hours in the prior 2 years. In 2017 (HPNA, 2017a), more than 811 CHPLNs had successfully completed the certification requirements.

Certification, as defined by the American Board of Nursing Specialties (ABNS, 2017), is “the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal patient care.” Certification is valued for the following reasons:

PRINCIPLES OF PALLIATIVE CARE AND RELEVANT CONCEPTUAL FRAMEWORKS

A core principle of PC across the entire disease spectrum and in all settings is the concept that the patient and family constitute the unit of care. The patient and family, rather than the disease, are the primary focus of care. The constructs of family-centered care form the foundation of the PC philosophy. PC addresses the meaning of disease, suffering, life, and death within the context of each family unit (NCP, 2013). PC recognizes that each family member will experience the disease process and all of its implications within the context of his or her particular worldview, and individual care plans are developed to reflect these worldviews. Another core PC principle is the commitment to collaborate through an interprofessional team process (Cairns & Yates, 2003; Leslie, Adams, & Kutner, 2002; Meier & Beresford, 2008; NCP, 2013; Oliviere & Hargreaves, 2017). So as to assist a family in crisis to establish and then achieve mutually agreed-upon goals, the PC team integrates and coordinates the assessment and interventions of each team member and creates a comprehensive plan of care.

Good PC is significant in the manner in which it embraces cultural, ethnic, and faith differences and preferences while interweaving the principles of ethics, humanities, and human values into every patient- and family-care experience (Dy, Lupu, & Seow, 2012; Morrison & Meier, 2004; Oliviere & Hargreaves, 2017). Furthermore, clinical ethics is an essential footprint for the provision of palliative and EOL care. Although clinicians often learn the theoretical principles behind ethics (Beauchamp, 2003; Dy et al., 2012; Morrison & Meier, 2004), PC necessitates that these principles be incorporated into the practice or “put into motion” 24 hours a day, 7 days a week (Block, 2007; Bruera & Hui, 2012). PC embodies this concept of ethics in motion, as each interprofessional team member, including patient and families, contemplates the ethical questions in advanced disease and in EOL decision making. Ethical challenges present themselves to the PC interprofessional team on an hourly basis.

Several conceptual frameworks or middle-range theories in nursing or related health disciplines provide a lens in both the assessment and treatments of PC patients and their families. The founder of St. Christopher's Hospice in London, Dame Cicely Saunders, put forth a conceptual model of “whole-person” suffering. Saunders espoused that whole-person suffering has four dimensions: physical, psychological, spiritual, and social (De Lima & Pastrana, 2016; Mount, Hanks, & McGoldrick, 2006; Oliviere & Hargreaves, 2017; WHO, 2007). Under this concept, suffering affects each domain of the biopsychosocial–spiritual aspects of care. This conceptual model forms the basis for the description of PC nursing practice. Also relevant is the Calkin model of advanced nursing practice (Bryant-Lukosius, Dicenso, Browne, & Pinelli, 2004), which serves as an excellent model on which to base PC advanced practice nursing. Calkin defines the clinical judgment abilities of three nursing practice levels as novice, expert by experience, and the master's-prepared nurse. The following case study illustrates Saunders's four dimensions of human suffering within the context of Calkin's model. The case study also demonstrates the APN subroles of expert clinician, educator, consultant, researcher, and collaborator (Callaway, 2012; Chulk, 2008).

ASSESSMENT OF THE PATIENT AND FAMILY

Through daily interactions with Mrs. S. and her family, the APN on the PC unit built a therapeutic relationship that focused on all dimensions of human suffering: physical, psychological, spiritual, and psychosocial. Despite the aggressive titration of pharmacotherapy being used to treat Mrs. S.'s pain, she continued to suffer from intense neuropathic discomfort. Her pain rating consistently was eight or above out of 10 on a visual analog scale, and over time, her sense of despair about dying in such agony was increasing. In consultation with other interprofessional team members, the APN was analyzing current research and consulting with other pain experts for novel approaches in treating neuropathic pain. The use of intravenous lidocaine has been successful in similar scenarios, and after critical analysis by the APN, the interprofessional team decided to try this therapy. The APN presented all the literature regarding the use of intravenous lidocaine in refractory neuropathic pain to the hospital's quality committee. The committee granted permission for immediate use and requested that the APN develop an evidence-based guideline to be used in future for patients with neuropathic pain. The APN quickly developed an evidence-based guideline as the neuropathic pain was escalating daily. The next step was to educate all team members, specifically, the nursing and pharmacy staff, as well as the patient and family, about the etiology, sequelae, and rationale for choosing this intervention. Mrs. S. received a test dose of the lidocaine and her pain decreased about 10% within 1 hour. Thus, the intravenous lidocaine was deemed appropriate to continue. Over the next days, her pain level decreased to two out of 10. Respecting the value of nonpharmacological measures in relieving pain, the APN assisted in having Mrs. S. offered massage and music therapy. She declined guided imagery.

While Mrs. S. was experiencing her pain crisis, the APN spent a lot of time with her, thus allowing an opportunity for Mrs. S. to express her feelings and fears. She revealed that she felt close to death and was struggling with guilt about one of her desires upon dying—that of spending her last minutes alone, if possible. She was fearful that this request would offend her very protective and involved family. But she had lived a very independent life and wanted to die that way. The APN listened, reflected, and assessed the situation and reported her findings to the interprofessional team. Based on the APN's observations and recommendations, the interprofessional team members set forth a plan to help Mrs. S. and her family deal with these very important issues. Social work and chaplaincy intensified their involvement.

Through interventions by the interprofessional team, Mrs. S.'s family was learning to become more comfortable with respecting her request and were working through their feelings of “abandoning” their wife and mother in time of need. This would continue to be a process.

With in-depth knowledge of family systems theory, the APN identified the need for the interprofessional team to address the already actualized loss of Mrs. S.'s role within the family, including that of mother and wife. The APN consulted the bereavement counselor as an early intervention for high-risk grief status, as Mrs. S.'s family was still dealing with their loved one's request of dying alone.

Progressively, Mrs. S. showed signs and symptoms of nearing death. As her pain increased, the APN adjusted Mrs. S.'s pain regimen so that she would remain comfortable. The APN and the interprofessional team increased support to Mrs. S.'s family to help them honor her wish for privacy at the time of death.

By maintaining a consistent presence with the patient and family and among the interprofessional team members, the APN helped to minimize decision-making conflicts. With advanced knowledge in the humanities, the APN, through language and image, gave expression to the experience of illness, death, grief, and human suffering.

DISCUSSION OF THE ADVANCED PRACTICE NURSE'S ROLE

Clinician. The APN utilized sophisticated and appropriate assessment strategies to evaluate pain and symptoms. The APN interfaced with other interprofessional team members to develop and implement a comprehensive plan of care. The APN identified novel approaches to the treatment of neuropathic pain and developed hospital-based standards of practice to reflect and support this treatment strategy and then executed the interventions. Advanced clinical knowledge of complex pain syndromes and comfort measures used to address symptoms was demonstrated through utilization of innovative, ethically sound, and scientifically based practice.

Educator. The APN facilitated complex philosophical, ethical, and clinical management discussions that assisted the patient, family, and all interprofessional team members in achieving a positive outcome. The APN assessed the learning needs of Mrs. S. and her family and the entire staff. The APN presented scientifically based education on the following issues: (a) the management of neuropathic pain, (b) the potential for role conflict, (c) the actual loss/anticipatory grief, and (d) the potential for high-risk bereavement. The APN also educated other disciplines; for example, she influenced the quality committee and pharmacy staff through in-service activities and guidelines on the philosophy of PC and developed individualized treatment strategies, most notable, the use of intravenous lidocaine for intractable neuropathic pain.

Researcher. The APN generated new knowledge through research and the translation of evidence into practice. The APN investigated and integrated PC research strategies, for example, the use of intravenous lidocaine, to formulate an individualized plan of care for Mrs. S.

Collaborator. The APN mentored staff in biopsychosocial and spiritual assessments and interventions. The APN built and preserved collaborative relationships and identified resources and opportunities to work with PC colleagues. The APN facilitated the development and implementation of staff forums, in-service training, physician–nurse collaboration, and quality committee consultation. The APN demonstrated the value of collaboration with the patient and family, the interprofessional team, and other healthcare professionals to facilitate the best possible outcome.

Consultant. The APN consulted with the PC physician, PC colleagues, and quality-committee representatives to determine the appropriate treatment strategies for meeting the needs of the patient and family. Also, the bereavement counselor was consulted after the APN identified the actualized loss experienced by Mrs. S.'s family. As a consultant, the APN was consistently available to the patient and family, interprofessional team members, and other healthcare professionals to discuss and explain issues surrounding the PC philosophy.

CONCLUSIONS

Generalist nurses and APNs in PC and hospice care bring a specific and well-defined set of qualities, knowledge, and judgments to caring for individuals and families facing serious, progressive, or life-threatening illness. This includes advanced scientific and biopsychosocial–cultural–spiritual knowledge, analytical skills, and mastery of a broad repertoire of communication and interpersonal skills.

Evidence suggests that early interventions of PC improve QOL, cost of care, and even survival in patients with metastatic cancer. Until recently, data from RCTs demonstrating the benefits of PC in patients with metastatic cancer who are also receiving standard oncology care have not been available (Smith et al., 2012). PC is an emerging specialty within healthcare and nursing. The philosophy and delivery of PC transcends all areas of nursing where suffering accompanies illness. The PC nurse is a true leader within the interprofessional team and hence is in an ideal position to establish standards for consistent practice, foster education, and promote research. It is a professional privilege to be in the field of PC nursing as it brings hopefulness to areas of EOL care that traditionally have been avoided—for example, ethics, pain, and human suffering. Equally applicable to the art of PC nursing practice is Thoreau's (1854) statement: “It is something to be able to paint a picture, or to carve a statue, and to make a few objects beautiful. But it is far more glorious to carve and paint the atmosphere in which we work, to affect the quality of the day—this is the highest of the arts” (p. 90).

REFERENCES