Research has demonstrated that integrating palliative care early for patients with advanced cancer improves outcomes such as quality of life, mood, patient satisfaction, prognostic understanding, health service use, and survival.
Polly Mazanec, PhD, ACNP-BC, AOCN, ACHPN, FPCN
Pamela Malloy, MN, FPCN, from the American Association of Colleges of Nursing
Pamela Malloy, MN, FPCN
Polly Mazanec is adjunct assistant professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, and a palliative care nursing education consultant. Pamela Malloy is director and coinvestigator of the End-of-Life Nursing Education Consortium (ELNEC) Project, American Association of Colleges of Nursing.
Research has demonstrated that integrating palliative care early for patients with advanced cancer improves outcomes such as quality of life, mood, patient satisfaction, prognostic understanding, health service use, and survival.1 As a result of groundbreaking research during the past 6 years, the American Society of Clinical Oncology promoted integrating palliative care into standard oncology care at the time a patient is diagnosed with advanced, metastatic disease.2 However, much work remains to be done. Most recently, the Institute of Medicine has called for improving quality of palliative care, especially nearing end of life in its 2014 report highlighting the barriers to accessing quality palliative care, among them, fragmented care delivery systems, lack of service coordination, and unsustainable costs for care.3
Oncology nurses can be instrumental in breaking down existing barriers and are essential partners in the delivery of quality palliative care to their patients and families. In its 2014 position paper, “Palliative Care for Persons with Cancer,”4 the Oncology Nursing Society recognized that oncology nurses are in a unique position to advocate for patient access to palliative care and that oncology nurses must possess the knowledge and skills required to meet the recommendations for the eight domains of palliative care in the National Consensus Project (NCP) Guidelines: structure and processes of care, physical aspects of care, psychological and psychiatric aspects of care, social aspects of care, spiritual, religious, and existential aspects of care, cultural aspects of care, care of the patient at end of life, and ethical and legal aspects of care.5
Since 2000, the End of Life Nursing Education Consortium (ELNEC) has educated over 19,950 ELNEC trainers from all 50 states, with content translated into nine languages. ELNEC’s Core Curriculum is divided into eight modules closely aligned with the NCP Guidelines: palliative nursing care; pain management; symptom management; ethical/legal issues; cultural and spiritual considerations in end-of-life care; communication; loss, grief, and bereavement; and final hours.
Most adult oncology nurses take the ELNEC-Core Course, and since 50% of the test items on the Oncology Nursing Certification Corporation examination are based on the NCP’s domains of palliative care, the ELNEC-Core Course can be extremely helpful to oncology nurses preparing for the OCN, AOCNS, and AOCNP certification exam.
The ELNEC curriculum gives oncology nurses the generalist palliative care knowledge that they need to care for patients, families, colleagues—and themselves. For example, in the pain management module, opioid equianalgesic conversions are discussed so that the oncology nurse can readily identify if a cancer patient in severe pain is receiving the appropriate dose of pain medication; if not, the nurse can advocate for the correct dosing.
Managing symptoms like fatigue, nausea and vomiting unrelated to chemotherapy, and dyspnea, are presented in the symptom module. Strategies to deal with ethical dilemmas that cause moral distress for oncology nurses, such as futile cancer treatments in the last days of life, the use of aggressive technologies that do not support patient goals of care, and family conflicts, are presented in the communication and ethics modules. Supporting patients and families dealing with anticipatory grief is addressed in the loss, grief, and bereavement module, as well as the importance of self-care for the oncology nurse dealing with multiple losses. For more information about ELNEC and/or to register for an upcoming course, go to
Generalist and specialty palliative care education also is available through schools of nursing. At Frances Payne Bolton (FPB) School of Nursing, Case Western Reserve University, the faculty is committed to preparing undergraduate and graduate students to provide palliative care to oncology patients and those with life-limiting illnesses.
The ELNEC core curriculum is integrated into the final clinical undergraduate course. With the leadership of Carol Kelley, PhD, ANP-BC, all MSN students in adult-gerontology primary and acute care, family, pediatrics, midwifery and anesthesia are required to complete the ELNEC training prior to graduation. The training is part of a 2-day one-credit course which includes a day devoted to ethical issues. Students receive a certificate acknowledging that they are ELNEC Trained and this certificate becomes an important part of their graduate portfolio for future employment.
Additional education is available for those who are interested in specialty training in palliative care and oncology. The MSN program at FPB offers five credits at the graduate level (3 credits palliative care and 2 credits oncology) to provide additional expertise in such specialty palliative care skills as advanced pain and symptom management and advanced communication skills. Most oncology nurse practitioners do not get this content in their generic graduate training. These four courses prepare practitioners with such skills as leading an interdisciplinary team, holding family meetings, and managing complex pain and symptoms associated with advanced cancer. For more information, visit http://fpb.case.edu/MSN/adultgero.shtm.
Oncology nurses have the responsibility and the power to influence their patients and the public by integrating palliative care into quality cancer care. ELNEC training can provide oncology nurses with the tools to improve the quality of life and quality of care patients and families receive.
1. Bauman JR, Temel JS. The integration of early palliative care with oncology care: the time has come for a new tradition. J Natl Compr Canc Netw. 2014;12(12):1763-1771.
2. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.
3. Institute of Medicine. Dying in America: Improving Quality & Honoring Individual Preferences Near the End of Life. Washington DC: National Academy of Sciences. http://iom.nationalacademies.org/~/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf. Accessed July 14, 2015. 4. Oncology Nursing Society Position Statement. Palliative Care for Persons with Cancer. 2014. https://www.ons.org/advocacy-policy/positions/practice/palliative-careAccessed July 14 2015.
5. National Consensus Project. Clinical practice guidelines for quality palliative care, 3rd ed. 2013. http://nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf. Accessed July 15 2015.