Brokering Early Palliative Care: How Nurses Approached a Misunderstood Topic

Oncology nurses are in an ideal position to recommend early palliative care for patients. For this reason, in a recent Canadian study on brokering palliative care, researchers looked at the role of nurses as advocates for early palliation.¹ Oncology nurses in Canada have different roles than their counterparts in the United States; staff nurses cannot refer patients for palliative care, but advanced practice nurses and nurse practitioners can. They identify patients who would benefit from early palliation and introduce or “broker” the concept to the patient and the doctor.

A stigma is still associated with palliative care as some clinicians continue to believe that the concept undermines a curative intervention. However, palliative care can be effectively introduced along with other treatments, and the combination of care improves patient symptoms and quality of life. Nurses, because of their routine interactions with patients, can participate in deciding who would benefit from palliation, acting as intermediaries between the oncologist and the patient in such situations.

Researchers undertook a study to explore the unique psychosocial processes utilized by ambulatory care oncology nurses in introducing early palliative care to those patients the nurses felt would benefit from it. The study took place at Princess Margaret Cancer Centre, a comprehensive cancer hospital in Toronto, Canada.  Ambulatory care clinics, organized by disease site and primarily staffed by oncologists, advanced practice nurses, and registered nurses, provide outpatient oncology care. A number of the clinics are led by nurses and nurse practitioners, who in turn address patients’ symptoms and treatment concerns with the oncologist.

For the study, the Canadian group recruited 20 nurses: 10 nurse practitioners, 6 staff nurses, and 4 advanced practice nurses. Eighteen of the nurses were female; all ranged in age from 25 to 64. The primary goal of the research was “to conceptualize the psychosocial processes” involved in brokering palliative care by oncology nurses. The secondary goal was to determine how nurses draw on their relationships with patients when providing care. An oncology nurse who was a postdoctoral research fellow at the time conducted the one-on-one interviews, either in person or on the phone; each interview lasted approximately 1 hour.

Brokering Palliative Care

To “sell” palliative care to patients, a nurse would approach a patient and say, “We have a team here in the hospital. They’re really strong doctors and nurses and they help patients manage all these symptoms.”  Aware of the stigma of palliative care, the nurse would not actually mention the term palliative care until the end of the discussion. Some nurses would bring the subject up “in the moment.” One clinical nurse specialist told the interviewer that sometimes she tells the patient, “I’m going to push this door open. You can close it and tell me to shut down.” That leaves the decision to the patient.

Staff nurses were particularly aware of the restriction of brokering early palliative care within the parameters of their roles. Staff nurses could not make a formal palliative care referral without first clearing it with the attending physicians. Oncology nurses employed “wait and see” and “build trust, then discuss” strategies to introduce the concept of early palliative care to patients.