Promoting Excellence : Urban Trauma/Emergency Center

Palliative Care Service
Detroit Receiving Hospital
Detroit, Michigan

Meg Campbell, RN, MSN, FAAN

Meg Campbell Detroit Receiving Hospital (DRH) has made remarkable strides in providing palliative care to its patients. Meg Campbell, a nurse practitioner who currently leads the DRH Palliative Care Service, began her career in critical care nursing in the early 1970s when the field was expanding rapidly. “We were learning how to keep people alive who would ordinarily die, but we didn’t know which patients would actually benefit from these procedures,” Campbell recalls. “Do not resuscitate (DNR) orders were rare at the time, and it was not unusual to resuscitate people again and again in hopes of bringing them back from the brink of death. Intuitively, we knew which patients would die, but we didn’t know what else to do.”

When the opportunity presented itself, Campbell accepted the challenge of providing palliative care to patients at DRH, which is an urban tertiary care center. “I knew it was what I wanted to do. I already had excellent communication skills and a critical care background,” she explains. The past 13 years have proven her right. Today, Campbell asserts, “Palliative care is the best work I’ve ever done.”

Palliative Care as a Subspecialty
In Michigan, APNs have considerable independence as care providers—including prescription-writing privileges. Although APNs have to work with a physician to prescribe Class II medications, direct supervision is not needed. “We can provide what patients need at the time they need it. That makes all the difference in the APN’s role and in patient care,” Campbell explains.

DRH’s Palliative Care Service, which is integrated into the entire hospital, is considered a subspecialty. “I focus on patients who are not expected to survive their hospital stay,” says Campbell. “It doesn’t matter what disease or injury a patient is dying from or where in the hospital he or she is.”

Campbell intervenes when a patient has an uncertain or poor prognosis. Using predictor models, she assists the medical team in recognizing the patient’s prognosis and then identifies appropriate interventions. Campbell assesses the patient and explores the value of palliative care with the medical team. She also works cooperatively with the hospital’s pain service.

DRH serves mostly indigent patients who typically do not have a primary care provider. In most cases, there are no previously established physician/patient relationships. “In about 85 percent of cases, the attending physician and resident team sign off on the patient when we sign on,” Campbell explains. She provides a traditional consult service for the other 15 percent of patients whose physician and resident team wish to continue writing orders and directing care. Campbell’s Palliative Care Service is solely hospital based. A small number of patients, fewer than 10 percent, are discharged from the hospital to receive ongoing home-based or facility-based palliative care via hospice providers in the community.

Although Campbell does not have a standing palliative care team, she insists she has something even better. “I have access to anyone I need from the hospital or university,” she explains. “Unlike the hospice model in which team members are fixed, the hospital-based practice at Detroit Receiving is just me—but I can involve a chaplain, social worker, dietitian, psychologist, wound specialist or whomever the patient needs.”

Early hospital data showed that even though Campbell was seeing 40 percent of non-trauma patients, her interventions were coming later in the illness or injury course than optimal—this despite efforts to educate medical staff regarding the benefits of early palliative care. In recent years, however, Campbell has focused on finding cases rather than waiting for referrals. Before starting her case-finding effort, she was seeing 27 percent of patients who needed palliative care. Now, she sees nearly 100 percent of eligible patients.

Funded by Cost Savings
Campbell is a salaried employee of the hospital, which bills for patient care, but not specifically for Campbell’s services. Most patients are covered by Medicare or Medicaid. The hospital funds Campbell’s position because of the cost savings associated with avoiding unwanted and excessive treatment and unnecessary ICU days. Hospital data suggests that her interventions are saving, on average, five ICU days, and more than $5,500 per patient.

Campbell is constantly collecting cost data on the effect of the Palliative Care Service. “I’ve kept a data set to justify the impact of the practice,” she says. “I can show how the number of consults impacts the institution’s bottom line.” Campbell notes that collecting data has preserved the program at times when budget cuts resulted in the elimination of other programs.

Education and Emulation
Campbell orients all new hospital nursing employees, introducing them to the Palliative Care Service, explaining what she does, and letting everyone know when and how to reach her. She also teaches nursing students at local colleges and universities and is an assistant professor of medicine at Wayne State School of Medicine in Detroit, where she participates in the ethics course taught to second-year medical students. In addition, Campbell presents cases at the department of internal medicine’s morning report, lectures in grand rounds, and conducts bedside teaching with nurses and physicians at every consult.

Campbell explains that other hospitals in Detroit and in Michigan have put similar programs in place. One of Campbell’s advanced practice nursing graduate students started a program at St. Joseph Mercy Hospital in Pontiac. The Fairview Health System in Minnesota is also emulating Campbell’s model.

Personal Reflection
In addition to collecting financial data, Campbell also assesses patient satisfaction. “The way I know it’s working is when the family can relax and even joke, when they can sit together and tell stories to one another,” she explains. “Some people laugh, others cry, but they no longer fret. They know what is going on and that the patient is comfortable. When that happens, I know all is going well.” Campbell also has one other measurement method: “I practice in the most litigious county in the state, and, despite the fact that so many of our patients die, we’ve never been sued.”

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

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