An adult is presumed to have the ability to make his or her own healthcare decisions—including termination of life-sustaining technology—unless he or she is shown to be incapacitated by clinical examination or ruled incompetent by a court of law. Advance care directives are legal vehicles used by people to provide guidance to their healthcare providers concerning the care they would desire in the event they become incapacitated and cannot make their own decisions. Problems with advance directives may arise when they do not seem to apply to the patient’s situation. Nurses roles include educating the patient and family about the patient’s condition and legal end-of-life (EOL) choices, identifying the patient’s and family’s wishes for EOL care, articulating the patient’s and family’s desires to other members of the healthcare team, and assisting the patient and family to obtain necessary and appropriate EOL care.

Cancer is a devastating diagnosis that many individuals still associate with death. Upon initial diagnosis, individuals embark on a treatment journey that is overwhelming with medical jargon, new healthcare providers, unknown outcomes, and fluctuations of hope amid the distressing effects of the disease and its treatment. The most frequently diagnosed adult cancer types are female breast, prostate, lung, and colorectal cancer. These four most commonly occurring cancers will be the focus of this chapter. The overall incidence and prevalence of cancer has increased with individuals living with cancer as a chronic illness. Treatment options have improved survival rates, decreased toxicity, and provided palliation. Symptoms associated with the disease and the toxicities of treatment require a commitment to an interprofessional model of care across healthcare settings. Palliative care focuses on the physical, psychosocial, and spiritual needs of the cancer patient and family as well as bereavement needs of families.

This chapter focus is on sexual health. Sexual health is a broad concept made up of multiple facets such as sexual desire, self as a sexual being, sexual orientation, sexual lifestyles, and relationships. Intimacy, closeness, communication, and emotional support affect all facets of sexuality. Sexual health within the context of palliative care may be directly impacted by the disease on anatomical structures. However, direct anatomical effect is not the only concern; changes in a person’s sexual interest or desire may also be affected by direct or indirect consequences of medical treatment or in association with being terminally ill. Illness involving sexual organs increases the likelihood of retraumatization for those who have experienced previous sexual trauma. Healthcare practitioners (HCPs) frequently avoid talking about sexuality with cancer patients. HCPs’ barriers to discussing sexuality include embarrassment, misinformed beliefs and assumptions, lack of knowledge, inadequate communication skills, and time constraints.

When nurses communicate with their dying patients and the patients’ families, they have a clearer understanding of their patients’ needs and goals at the end of life. This chapter explores ways to encourage both nursing students and graduate nurses to facilitate communication with dying patients, their families, and their healthcare providers. It also explores ways in which nursing faculty members might assist undergraduate nursing students to enrich themselves by working with dying patients. The chapter is organized according to the phases of the therapeutic relationship because in many ways the phases of the therapeutic relationship—introductory, working, and termination—parallel the dying trajectory. When appropriate in the phases, distinctions are made between the roles and educational needs of the undergraduate nursing student, the nurse with an undergraduate degree, and the nurse with an advanced practice degree.

The diagnosis of end-stage renal disease (ESRD) can be difficult for patients and families to hear because this means they will need some form of kidney replacement therapy to survive (hemodialysis, peritoneal dialysis, transplantation). ESRD means a patient has severe end-organ kidney damage and failure. When confronted with the extensive list of medical and psychological problems often associated with patients with ESRD, healthcare professionals often focus on treating the medical issues by implementing strategies to address abnormal laboratory values and treating comorbid conditions. The goal for patients with ESRD cannot be simply to preserve life but also to promote quality of life. This chapter discusses palliative care in relation to three groups of patients with ESRD: undergoing dialysis, choosing conservative management, and withdrawing from dialysis. It also provides a brief review of the major comorbidities and complications associated with ESRD and available palliative treatment options.

It has been said that working in interdisciplinary teams is a core competency all health professionals will need in the 21st century; they need to be able to collaborate, coordinate, and, most of all, communicate with one another in order to optimize care and maximize operational excellence. Nurses need to be active in interdisciplinary organizations from the start of their careers, and present/publish their work in interprofessional forums. Nurses have many advantages in interdisciplinary collaboration—sound basic education in humanities, social sciences, and basic sciences; many community connections; and experience in facilitating care across different providers. Interdisciplinary opportunities provide more prospects for effecting large-scale change than discipline-specific opportunities do. Moving beyond the discipline specific doesn’t mean that nurses leave nursing; it means they assume positions in which they can now advance the perspective of nursing in ways that others can appreciate, while attracting additional public support.

The prevalence of depression, burnout, suicidal intent, and chronic health conditions is higher in healthcare clinicians than in the general population. Pediatric clinicians face unique challenges when delivering patient care due to the complexity of the family dynamics and the special needs of caring for an ill child. Burnout consists of emotional exhaustion, no longer finding work meaningful, feeling ineffective, and a tendency to view patients, students, and colleagues as objects rather than as human beings. Conditions associated with burnout include headaches, tension, insomnia, fatigue, anger, impaired memory, decreased attention, thoughts of quitting work, drug and alcohol use, and suicide. Burnout not only has adverse effects on clinician population health and healthcare quality and healthcare safety, but it contributes to high turnover and substantial financial losses. Good self-care by pediatric clinicians and systems that support clinician wellness are imperative to prevent burnout, compassion fatigue, and other mental health disorders.

No two offices are the same when it comes to providing for the psychosocial needs of one’s primary care patients. Many offices are integrating mental/behavioral health therapists in their medical home. However, given limited access to psychology and psychiatry resources for children, many primary care providers also are finding themselves taking over the prescribing duties for psychoactive medications. Getting reimbursed for the time and effort that is spent caring for children with psychosocial and mental health issues requires a working knowledge of the diagnostic coding system and local practices of third-party payers. Certain billing codes are meant for primary care providers or psychiatric nurse practitioners while others are restricted for use by psychologists and master’s level therapists. This chapter discusses the reimbursement for mental/behavioral health services in primary care.

Increasingly, women are using complementary and alternative medicine (CAM) therapies for preventive and palliative care as alternative or adjunct therapies to their traditional medical care. This chapter discusses the most commonly used therapies for a variety of conditions that affect women. Women may not perceive vitamins, minerals, herbs, and supplements as medications. Because drug interactions exist with both prescription and over the counter products, it is important for the clinician to ask each woman about the use of CAM therapies at every visit. Women who are pregnant and/or breastfeeding should not use any CAM therapies without consulting their health care provider. Alternative therapies refer to treatment approaches that, though used for many years, have not been evaluated and tested by conventional methods and rigorous research. The chapter provides the general categories of CAM, reasons for selection/use of CAM, concerns regarding CAM, considerations, and frequently used/recommended CAM therapies.

As a health-care provider, one must be able to accurately and efficiently correlate subjective information with objective findings. This is especially important in electrocardiogram (EKG) interpretation. This chapter presents patient’s basic history and a corresponding EKG for clinical practice. Space is provided to document the pertinent findings. The exercises include heart rate calculation, rhythm evaluation, axis evaluation and heart block assessment including sinus block; first-, second-, or third-degree atrioventricular (AV) block; bundle branch block; and QT prolongation. It also includes evaluation for signs of ischemia and infarction and strain patterns such as those seen in ventricular hypertrophy and consider atrial enlargement. The chapter aims to improve EKG interpretation skills.