Kathy Ryan, RN, is an expert in critical care nursing. A nurse for 17 years, Ms. Ryan works in the most technologically advanced setting — the Medical Intensive Care Unit (MICU) at Massachusetts General Hospital. Omnipresent at the bedside, Ms. Ryan expertly monitors physiological responses, titrates multiple IV drugs, and operates critical equipment. Through close surveillance, she is able to detect subtle and early changes in her patients’ conditions.
What sets Ms. Ryan apart from other critical care nurses is her advanced knowledge of palliative care. This knowledge allows her to shift fluidly to compassionate end-of-life care for those patients who will not recover. Ms. Ryan is able to focus on supporting the grieving family and on achieving a peaceful death.
Ms. Ryan remembers a patient with a sweet tooth. The woman’s elderly sister would bring Hershey’s Kisses to the MICU, sharing with Ms. Ryan how as little girls the sisters would sneak candy when their mother wasn’t looking. On what turned out to be the final day of her life, the patient was no longer lucid. Ms. Ryan went to the hospital gift shop, returning with a small package of Hershey’s Kisses. Instead of using a medical swab to wipe the patient’s mouth, Ms. Ryan touched the chocolate candy to the patient’s lips while the woman’s sister watched and smiled.
A Powerful Personal Gesture
This powerful personal gesture affirmed a happier time of life and the bond between the sisters. Amid the hospital’s busy pace, the nurse took time and acted on behalf of both sisters; the surviving sister’s memory of her sister’s death will include a smile.
Taking time to listen to families was one of the lessons Ms. Ryan shared with other nurses when she participated in a Mass General nursing residency focused on palliative and geropalliative care. Palliative care is a movement to help patients and families optimize quality of life, enabling informed decisions that fit patients’ and families’ values and goals. Geropalliative care addresses many of those same issues, focusing on care of adults over 65 years age.
Taking the time to listen to families was one of the lessons involves in a Mass General nursing residency program focuses on palliative and geropalliative care.
The residency program sought to empower and inspire nurses and improve care for older adult patients and other patients nearing the end of their lives. Through educational sessions, nurses learned how to respond to questions about death and advocate to physicians and hospital staff on behalf of patients.
The idea for the program sprung from an effort to address the nursing shortage and the need to strategize how health care would address the “silver tsunami” — the fast-approaching aging of the American population, says Jeanette Ives Erickson, RN, DNP, FAAN, senior vice president for Patient Care and chief nurse at Mass General.
Dr. Ives Erickson says she and Ed Coakley, RN, MSN, MA, MEd, director emeritus for the Department of Nursing, sought to retain older nurses and a new generation of nurses. The residency targeted two groups at high risk of leaving their jobs: nurses with more than 20 years of experience and nurses with two to five years. Content focused on geriatrics and end-of-life care, topics that are not comprehensively addressed in formal prelicensure education.
Protecting the Nurse-Patient Relationship
The residency evolved into the Mass General AgeWISE program. In the future, Mass General intends for additional unit-based nurses to attend training. In 2010, the Center to Champion Nursing in America, an initiative of the AARP, the AARP Foundation and the Robert Wood Johnson Foundation, provided partial funding for Mass General to pilot the educational program to six academic medical centers. The Mass General-developed geropalliative care curriculum was well received at the other medical centers. In November, Mass General held its second national AgeWISE Summit, hosting 12 hospital organizations.
Dr. Ives Erickson says she and Mr. Coakley recognized the special relationship between nurses, patients and families. “We both felt that our job as leaders was to create an environment that protected the integrity of the nurse-patient relationship,” she says. “By really having the time and the opportunity, we’ve also established a new standard of care that’s being adopted by the nation.”
A steady presence at the patients’ bedsides, nurses are among the first providers to recognize a pattern in a disease and realize a patient’s final days are approaching, says Susan Lee, RN, PhD, AgeWISE program director at Mass General. Nurses may be the first healthcare professional a patient or family member queries regarding death or out-of-hospital care options. Giving nurses the tools to answer and enter into difficult conversations is crucial, Dr. Lee explains. “Nurses have this intimate relationship that allows the patient to say, ‘I’m scared,’ or ‘I’m not sure,’” she says.
Dr. Lee explains that older adults often have multiple medical conditions, possibly leading to complications and re-hospitalization. Additionally, geriatric patients more often experience delirium than younger adults when hospitalized.
“What I Do Matters”
Melissa Gentile McNamara, RN, a nurse of 10 years, says that in her cardiac unit she often cares for geriatric patients on the night shift. When her unit is quiet, sometimes nurses will place a geriatric patient in a comfortable chair with them at the nurses’ station. The companionship can prevent an anxious patient from becoming disoriented, Ms. McNamara says.
Through the residency program and with experience, Ms. McNamara says she’s learned how to initiate discussions about emotion-laden issues, such as loss of a patient’s independence. She explores families’ safety concerns, knowing a fall at home could lead to a broken hip and another hospitalization for their loved one.
Anne Marie Thompson, RN, a nurse of 20 years, has learned small changes make a difference. After participating in the program, she began getting patients in her cardiac unit out of bed and into chairs for breakfast. The new routine takes more time, but she’s noticed her patients seem better attuned to their surroundings. Ms. Thompson mentored Gina Ruscitti, RN, who works in the same unit. Miss Ruscitti, a nurse for 11 years, says she enrolled in the program with a passion for improving care for the older adult. In Thompson, she found an experienced ally. After the program, Miss Ruscitti felt invigorated and committed. “The residency validated that what I do matters,” she said.