Community-Based Nursing

Introduction

A common issue in hospice today is in the topic of community-based nursing, which includes hospice and palliative care for patients. Many times, patients are forced to give up certain therapies that could be very important to their recovery process in order to enroll in the hospice itself because of their insurance agencies, and because of the type of care that they need. The therapies that are being omitted are known as curative intent therapies, as well as palliative care and hospice. The topic at hand is that nurses face heavy difficulty in these situations because there is a lack of treatments for patients in hospice and palliative care because the patient should always be the first priority.

Nurses have seen a movement to community-specific care from working in institutions, but this then leads to frustration that can come from being a home nurse for patients, even in a program like hospice or palliative care. According to Roberta Hunt of the American Journal of Nursing, there are “defined essential components of community care… patient self-care, prevention, consideration of family, culture, and community, and continuity of care through collaboration” (p. 44, 1998). Nurses that work with these patients become frustrated in this situation because they do not always feel welcome, or feel frustrated by the restrictions of community-based care.

Hospice is a program that is meant to care for and support people who are terminally ill. They help people with these terminal illnesses to live more comfortably, and these include cancer patients. The focus of hospice is comfort, and not simply curing the illness. The nurses and other professionals at a hospice “provide care for the ‘whole person,’ including his or her physical, emotional, social, and spiritual needs” (Centers for Medicare and Medicaid Services, 2013). Physical care, medication, medical equipment, other supplies, and counseling are all meant to be located at a hospice for the patient’s illness and condition. Care can be provided at home, and family members who are caring for the patient get support (Centers for Medicare and Medicaid Services, 2013). Palliative care is provided throughout a patient’s illness, and other treatments that they may need, which include coordinated pain and symptom control, coordinated pain control, symptom control, spiritual or psychological needs, as well as family support and assistance during the transition.

However, the treatments that patients are being forced to give up because they fall in a ‘gray zone’ between disease-directed therapy and palliative care. They are not covered by the MHB, which stands for Medicare hospice benefits. They are treatments that are considered to be ‘usual’ rather than ‘aggressive’ to patient treatments (Center to Advance Palliative Care, 2014). Hospice care offers many of the same services. However, the difference between these two programs is that hospice care, as required by Medicare or other service providers, is restricted to six-month prognosis. Most providers do not cover the treatments that make an effort to“cure or prolong life” (Center to Advance Palliative Care, 2014). Palliative care is open to all patients, it does not require curative care, and the professionals work with several providers to make sure that all services that are needed are covered somehow.

Organizations that are collaborated in order to achieve their health goals because these goals cannot be completed alone; these health-related goals are in two categories: meeting the needs of individual patients, and then meeting the needs of the entire group. “The major difference between public and private sectors was that the former (including the Aboriginal medical service) were motivated to collaborate to achieve patient and population health goals, the latter by individual patient needs” (McDonald, Powell, Davies, Jayasuriya & Fort Harris, p. 260, 2011). The problem with the hospice care situation is that there is simply not enough flexibility to care for each patient individually. If they cannot afford the coverage plan that provides them the treatment that they need for their illness, they simply have to do without.

Even basic collaboration involves time and effort. These transactional costs were higher when the organizations differed significantly in size, structure, complexity and organizational culture. These additional costs, balanced against benefits, influenced the decisions about whether to collaborate, with whom and to what extent (McDonald, et al, p. 261, 2011).

This can be very frustrating for dedicated nurses and doctors that work in the hospice because they care about the patients and about their process through their illness.

Studies have demonstrated significant benefits in terms of symptomatic relief from many treatments considered to be disease directed. For example, several trials have shown that radiation therapy provides effective relief of cancer-related antimicrobials. One of the most important aspects of hospice care is symptom control (Reinbolt, Shenk, White & Navari, 2005).

Patients with advanced cancer tend to experience a very wide variety of infections, and they occur often. There are a large number of studies that have shown that patients receiving hospice or palliative care “are treated with antibiotics for suspected or documented infections” (Reinbolt, et al, 2005). This article covered two different studies that show how taking time to relieve a patient’s symptoms, called symptomatic relief, goes a long way.

In one study, 225 patients with advanced cancer (at the time of the study) entered a community-based outpatient hospice and a palliative care program. Prospectively, the use and effectiveness of the antimicrobials were documented during palliative care. One hundred and seventeen patients reported a total of 129 infections and the most common sites of these were urinary tract, mouth, pharynx, respiratory, skin, and subcutaneous tissue infections. One of the most commonly reported as far as organisms was E. coli. “The use of antimicrobials controlled symptoms in the majority of the urinary tract infections, but were less effective in controlling symptoms of the other sites of infection” (Reinbolt, et al, 2005). The treatment of symptoms is an important part of the care process in hospice. This is one of the frustrating situations for nurses in community-based care; treatments are denied to patients that may need them because of financial or legal means.

Patients, like those with advancing cancer, who are receiving hospice care, have a high incidence of infections during their time there. Typically, antimicrobials are prescribed for the majority of these patients: “with good symptom control in urinary tract infections, but symptom improvement in less than half of the patients with mucositis, respiratory tract infections, skin/subcutaneous infections, or bacteremia” (Reinbolt, et al, 2005). However, the survival of the patients is not seemingly affected by the use of antimicrobials for these infections (Reinbolt, et al, 2005). Patients and their families should be made aware of the limitations of this medication because of the number of infections that happen in advanced cancer patients.

In community-based nursing programs such as hospice, there is more of an emphasis on how much a patient is able to afford, and there is not only a time restriction but also for treatments that patients can receive via their insurance agency. The joy of community-based nursing is that nurses are able to give patients a full range of care and they can feel as if they are indeed doing the full range of the jobs. The reason for a comparison between palliative and hospice care is because of the range of community-based care in either program.

A good decision-making challenge is vital in this situation. It is an all-or-none decision because it is important to understand the challenges that nurses confront when providing care because of the financial and legal constraints of the agency and the patients, in both palliative care programs and hospice. In a situation such as one with restrictive therapy or treatments in Hospice, it is easy for a nurse to become frustrated. It is easier for those patients and nurses engaged in palliative care because the program encourages collaboration across sectors of health care providers for the patient, so they then can get the care and support that they need, not just what they can afford. A great deal of frustration as well stems from legal and financial restrictions because nurses are taught to treat every patient with respect and necessity. Nurses are no longer able to feel as they are able to give the patients the community-based care that they need, and feel frustrated that they may not be doing enough.

Conclusion

Patients in hospice are seeking comfort, support, and, overall, healthcare for their patients. It is unfortunate that hospice does not cover all of the services that they need, and basically gives them a time limit in which to heal. In palliative care, there is simply more time for treatment, and understanding how the patient’s needs should be treated. The financial restrictions, insurance concerns, and treatment options are a source of frustration for nurses throughout community-based care options like hospice and palliative care.

References

Center to Advance Palliative Care. (2014). Palliative Care vs. Other Service. Palliative Care Program. Retrieved from http://www.capc.org/building-a-hospital-based-palliative-care-program/case/definingpc/designing/presenting-plan/pc_vs_other/.

Centers for Medicare and Medicaid Services. (2013). Medicare Hospice Benefits. The Official U.S. Government Site for Medicare. Retrieved from http://www.medicare.gov/publications/Pubs/pdf/02154.pdf.

Hunt, R. (1998). Community-Based Nursing: Philosophy or Setting? American Journal of Nursing, 98 (10): 44-47.

McDonald, J., Powell Davies, Jayasuriya, R., & Fort Harris. (2011). Collaboration across private and public sector primary health care services: benefits, costs and policy implications. Journal Of nterprofessional Care, 25(4), 258-264. doi:10.3109/13561820.2011.566650.

Reinbolt, R.E., Shenk. A.M., White, P.H. & Navari, R.M. (2005). Symptomatic Treatment of Infections in Patients with Advanced Cancer Receiving Hospice Care. Journal of Pain and Symptom Management, 30 (2). Retrieved from http://www.sciencedirect.com.ezproxy.apollolibrary.com/science/article/pii/S0885392405002514/.