Palliative Roles & Responsibilities of Nurses

After spending a few days reading and blogging about Amanda Trujillo, the nurse and patient advocate in Arizona fired for overstepping bounds and informing a patient about hospice, I was ready to back turn to other research related to the work of the Community Ethics Committee. 

But today as I read “Palliative Care in the ICU,” a roundtable discussion newly published in the Journal of Palliative Medicine, I couldn’t help but think of Trujillo and nurses elsewhere who have rallied to her defense.

Much is unknown about what transpired at the Banner Health hospital the day last spring when Trujillo’s involvement in patient advocacy angered a physician and got her fired and otherwise barred from nursing in Arizona. But what does seem clear is that she acted in the best interests of the patient.

And so, as I read the comments of roundtable participant Kathleen Puntillo, R.N. and Doctor of Nursing Science in the Department of Physiological Nursing at UC San Francisco, regarding “the responsibilities of nurses and their valuable roles,” I thought immediately of Trujillo. I don’t know whether Puntillo is even aware of the Trujillo case, but her words were remindful of Trujillo’s own in explaining her actions.

“If nurses really are reminded of their responsibilities to be active members of all aspects of patient palliative care, then I think this gives them a framework from which to draw some confidence,” Puntillo said. “By that I mean that if you look at any of the major professional nursing organizations, the American Nurses Association, the American Association of Critical Care Nurses and some of the European nurses' organizations, over and over again they emphasize that the nurse's primary commitment to the patient is not just a right but a responsibility, this one duty trumps all others. We really must be more involved in palliative care. I think that lays a good foundation for nurses.

“Of course, the roles that nurses play are extremely important roles. Nurses are generally competent to take on a larger role, to discuss patient status with patients and families since they have more contact with patients than other clinicians in the ICU. They work frequently with dying patients. They hear discussions and conversations among family members, patients and multiple teams. So they do have the ability and the exposure to be involved.

“Now, to be a little bit more specific,” Puntillo continued, “nurses can, for example, be the leaders in interdisciplinary committees or work groups to improve palliative care efforts. They can easily, and often do, identify potential obstacles for improving palliative care in their particular ICU. They can be leaders in enhancing teamwork that is so important to palliative care interventions and efforts. They can identify work processes that will help to integrate palliative care interventions and so on and so forth. So nurses have tremendous roles to play.

“Within a family conference in which patients and families interests and needs are discussed, there are many specific things that nurses can do such as listening, facilitating, supporting the expression of empathy, and helping after the meeting to continue those conversations and clarify with other health care providers, as well as with family members who may not have heard everything during that meeting.

“Finally, I want to make one more point that nurses can really guarantee a patient's dignity or their right to respect and ethical treatment, because a lot of times patient dignity is lost due to their dependency, their symptom distress, privacy boundaries, and their feeling of being a burden to others. Nurses have a tremendous responsibility and right and role in this whole aspect of palliative care.”

Along with Puntillo, six others participated in the roundtable, moderated by Dr. Judith E. Nelson, of Mount Sinai School of Medicine in New York. The hearts and minds involved in this roundtable are impressive, and I’ll write more about their broader thoughts later.