The presence of palliative care in the United States is predominantly in the setting of end-of-life care—the APN’s valuable role in this area of health care is not well understood, with little or no data to support the positive outcomes that can occur between the APN, patient, and family. Palliative care in general, and in nursing specifically, has been accompanied by a preoccupation with questions regarding the benefits that may arise from referral to a palliative care service, or to a nurse specialist, despite the long history of advocating outcomes in nursing research (Corner, Clark, & Normand, 2002). This may come from the analogy of medicine’s evidence-based practice, which attempts to measure the impact of disease management on indicators of health outcomes (Corner et al., 2002). Therefore, the role of the APN in palliative care should reflect a genuine preoccupation with demonstrating the effectiveness of the care provided by APNs or whether a specialized palliative care service is of value (Corner et al., 2002). Macmillan nurses have been able to articulate and successfully demonstrate the value of their role in the care and management of patients living with and dying from advanced disease through clinical outcomes. APNs may consider applying the Macmillan nurse framework and the collection of clinical outcomes in their role as a palliative care provider in the United States. As APNs collaborate and clarify their roles in the provision of palliative care, they can aim to apply the best evidence to practice that can help to further inform and influence the development of policy and practice in palliative nursing. Clinical outcomes that will come from this role can further be used to correlate with conventional evidence to provide the best care for the patient and his or her family (Corner et al., 2002).

Guidelines are statements developed to provide practitioners and patients with information to assist in decision making regarding healthcare choices for specific clinical situations. They represent the culmination of experience, literature reviews, and state-of-the-art practice typically agreed on by consensus panels (Emanuel, Alexander, Arnold et al., 2004).

The ANA Social Policy Statement, revised in 1996, defined the four essential features of nursing practice (ANA, 1996a), to consider when developing practice guidelines:

The ANA also maintains that “advanced practice registered nurses integrate education, research, management, leadership, and consultation into clinical roles, and they function in collegial relationships with nursing peers and other professionals and individuals who influence the health environment” (ANA, 1996b).

These elements of basic and advanced nursing practice are intermingled throughout specific clinical guidelines to improve the quality of life for those patients with a life-limited diagnosis (English & Yocum, 1998). While many APNs practice independently, many state regulations require a collaborative practice arrangement, written or verbal, agreed on between an APN and a physician. Palliative care often presents clinicians with challenges outside of the scope of practice and expertise of many nurses. It is therefore important for the APN to identify possible interdisciplinary resources, including a physician versed in palliative medicine along with other members of the interdisciplinary team, to address and support the multiple needs of the patient living with chronic debilitating disease.

These nursing elements encourage the APN to define and develop specific guidelines with a collaborative physician. A carefully developed practice agreement that includes practice guidelines between the APN and collaborating physician allows the APN to practice independently within the scope of nursing practice and without the need to adhere to a rigid, preset course of action. The APN has the ability to use his or her level of expertise, scope of practice, and continued relationship with the patient and family to provide individualized and compassionate care.

Protocol is typically used within diplomatic circles but can also be applied to a variety of venues. Scientists have long used the term to define experiment or research designs. The dictionary defines protocol as a “correct code of conduct” (Yahoo Education, 2005).

In applying this definition to the APN’s practice, it can be used as an agreed-on set of expectations that are carried out when performing a specific procedure or task or managing a specific disease and/or symptom. As previously mentioned, the APN’s scope of practice is determined by the specific state practice act, institutional mandates, or both. Collaborative practice agreements (discussed later in this chapter) may also specify how protocols are utilized and incorporated into daily clinical practice.

Guidelines and protocols should permit the practitioner to incorporate the use of sound clinical judgment when providing individualized patient care, as opposed to rigid adherence to a step-by-step process. A rigid “cookbook” approach to symptom management does not take into account the individual situation and the resultant needs and responses of the patient. The pharmacological management of frequently occurring symptoms in a patient with end-stage disease requires careful assessment, individualized sequential trials of therapy, and ongoing evaluation and monitoring. The management of any symptom requires patience, experience, and ongoing education with the patient and family. While this is true in all clinical situations, it is especially important in palliative and end-of-life care. Applying algorithms specific to an individual symptom such as pain, dyspnea, or delirium may not necessarily produce the desired outcome. While the use of algorithms and care maps should not be discouraged, careful attention should be given to individual patient and family variations, their responses, and the context of care.

Guidelines can help to facilitate care toward best known practices, based on the current evidence. They serve to decrease the variability in care and to improve quality (Emanuel et al., 2004; O’Connor, 2005). It is important to update clinical guidelines or protocols with the integration of current evidence-based interventions. Maintaining an ongoing knowledge of the current research provides the APN with state-of-the-art interventions (evidenced-based practice). The use of guidelines and protocols that incorporate proven therapies benefits patients in everyday practice without sole reliance on personal intuition or anecdotal experiences.

The APN in palliative care is exploring ways and means to embrace evidence-based practice with a model of practice that includes clinical state, setting, circumstances, research evidence, patient preferences, healthcare resources, and clinical expertise. APNs practice from guidelines and protocols that should be tied into the growing body of science that is defining and promoting the field of palliative medicine.

The Centers for Medicare and Medicaid Services (CMS) in 1998 amended the definition of collaboration to read as follows:

Successful collaboration requires a re-thinking of the traditional medical hierarchical model of practice (Lysaught, 1986). In a collaborative practice arrangement, the APN and the physician can focus on a holistic approach to patient care. Collaborators are partners and not substitutes for one another who agree to ongoing participation in the patient’s plan of care (Berry & Kuebler, 2002; Lysaught, 1986). Figure 1-1 provides an example of a collaborative practice arrangement between an independent NP and a collaborating physician.

It is important to note that regardless of specific state practice acts that do or do not require a collaborative practice arrangement, in order for the APN to submit for a federal Medicare reimbursement provider number, a physician must be identified in the application process. A consulting and supportive physician relationship provides medical direction in the event that the APN’s clinical decision making occurs outside the scope of his or her practice (Buppert, 1999).

Currently in the United States, more than half of the states allow NPs to prescribe schedule II medications. Some of these states require a delegated authority, meaning that the collaborative physician delegates prescribing practices to the NP. Other states may limit prescribing practices to certain medication schedules (Kuebler, 2003). An example of a delegated prescribing arrangement is given in Figure 1-2.

The Medicare Prescription Drug Improvement and Modernization Act (MMA), better known as the Medicare Prescription Bill, included significant language influencing NP practice. After 2006, Medicare recipients without pharmaceutical coverage may want to enroll in the voluntary Medicare Endorsed Pharmaceutical Discount Programs made available through specific pharmacies and pharmaceutical companies (Towers, 2005). The APN may want to become familiar with the various options to explore with individual patients. An important component of this legislation is in the provision of direct reimbursement for serving in the capacity as primary provider for patients who are enrolled in the Medicare Hospice Benefit or in Medicare reimbursed skilled home care. Currently, NPs are not able to directly admit patients into hospice care (this requires two physicians who designate a limited prognosis of 6 months or less) or into the services of skilled home care. The NP, however, is able to seek reimbursement when providing services that reflect primary care management (Towers, 2005).