Registed Nurses' Association of Ontario

Supportive and Palliative Care Clinical Practice: Building Capacity at the Bedside

Rayelle Richard
The Ottawa Hospital

The RNAO Advanced Clinical Practice Fellowship (ACPF) occurred at The Ottawa Hospital (TOH), a tertiary care academic setting with inpatients as well as outpatient Supportive and Palliative Care clinics and other regional settings including regional hospices with the Palliative Pain and Symptom Management Consultation Service.

The RNAO ACPF, has been an amazing experience professionally and personally. The feelings of elation and gratitude, I had regarding the opportunity to work with nurse experts, physicians and social workers’ in palliative care has been very apparent to the team. Palliative Care is truly a passion for me. The philosophy, of whole person care, care of the family, normalizing death, comfort at the end of life, quality of living and dying, meaning, legacy and healing at the end of life are areas of immense interest to me. The opportunity to work within the inter-professional Supportive and Palliative Care Team as part of a dyad was a unique and educative experience. It highlighted to me the importance of inter-professional care and the benefits it provides for patient and team members. The level of capacity building that the Supportive and Palliative Care team has provided has been invaluable and has allowed me to have this intensive learning experience. I have done this through exposure to clinical experts, job shadowing, self reflection, education days, accessing palliative care educational resources, workshops, preparing presentations, participating in citywide rounds and site visits to other palliative care settings.

I felt comfortable with my clinical knowledge before beginning the Fellowship and hoped that it would assist me during my 3 months. I soon realized that the learning curve would be steep and my clinical knowledge was, but a foundation that I was going to build on. I have had many opportunities to increase my knowledge of comprehensive assessments and specialized interventions to manage physical and psychological symptoms experienced by patients with malignant and non-malignant life threatening illnesses as well as their families.

I have expanded my current pain management skills as I worked with patients that have complex pain issues. I have learned to complete comprehensive pain assessments by enhancing my existing knowledge of the different classifications of pain and their clinical presentation. I have also learned to use the different assessment tools like the BPI and ESAS, that allows patients to rate the severity of their pain and how it interferes with their feelings and function, Moreover, I have increased my understanding of appropriate pain management strategies used in palliative care (World Health Organisation analgesic ladder, commonly used opioids, side effects, opioid rotation/conversion, route of administration, adjuvant analgesics). I have also expanded my knowledge of common physical symptoms experienced by those with advanced disease including dyspnea, delirium, nausea/vomiting and constipation. In addition, I have developed experience in discovering the psychosocial needs of patients with advanced disease and learned communication techniques that facilitate discussion and intervention. These included discussion on goals of care and advanced care planning. Working in the dyad I was able to observe, learn and participate in theses discussions. I observed how the team would create a safe environment by listening to the patient and family as well as being mindful of the verbal and non-verbal cues in the room. I learned and participated in facilitating the processes of reflection and reminiscing with patients and their families. Having worked with different members of the team, I was in awe of how effortless these skills seemed to them and of how much information they gathered during many of these conversations. One of my favourite questions asked was “how are your spirits today?” despite nit being open ended it almost always elicited a response that allowed us to explore patients mood, hopes and even fears.

The Fellowship has been a journey for me, as I worked through my own fears of death and dying and whole person care. As an observer of life and death I feel as though we all have 2 tasks for us at the end of life. Firstly, we have our own fears, hopes and meaning that we each work through at the end of life. We all in different ways seek to find meaning and struggle with the loss of health and the eventual loss of our families. We seek to die with dignity, free from pain and often surrounded by our loved ones. This is why it is not enough to treat just the physical man, because it is never more clear then at the end of life that we are more then just our bodies. Secondly, we become teachers for those around us as they walk along side us on our journey both with the capacity to heal and the need for healing. We have the power to normalize death, to search for meaning and to acknowledge our fears and hopes. We can reminisce, talk about legacy, and the different facets of hope at the end of life. Understanding that this can sometimes be our greatest gift to the ones we leave behind, a healing in death.

Ultimately, this fellowship has highlighted the importance of symptom control at the end of life and how foundational it is for quality of life. I hope to take all I have learned and be a part in continued capacity building on my unit and at TOH. I am also very grateful to my manager, my mentor, my director, Lynn Kachuik and RNAO for this opportunity.

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