Promoting Excellence : Acute Care Teaching Hospital

Palliative Care Service
Massachusetts General Hospital
Boston, Massachusetts

Constance M. Dahlin, RN, CS, MSN, ANP

Constance M. Dahlin Ten years ago, Massachusetts General Hospital (MGH) was not the place one would expect to find expert palliative care. MGH is a premier academic teaching hospital that prides itself on cutting-edge, life-saving medical treatments. Thanks in large part to the efforts of Constance Dahlin, however, palliative care has also been incorporated into MGH’s daily activity.

Dahlin, a palliative care clinical nurse specialist and nurse practitioner, was one of the first members of the MGH palliative care team when it began in 1996. Today, in addition to Dahlin, the team includes two attending physicians, two physician fellows in palliative care training, a social worker, a bereavement/volunteer coordinator and an administrative assistant.

The MGH team provides a consulting service for patients who have life-threatening diagnoses and are in need of symptom management, psychosocial support, grief and bereavement counseling, discharge planning, and/or long-term care planning. The patients served need not be actively dying. The goal is to alleviate suffering and develop a plan of care that enables patients to return to their own communities with hospice or home health services and ongoing support from the Palliative Care Service. “It’s my job to make sure that each patient’s needs are met at every stage of his or her illness,” Dahlin explains.

Continuity of Care
In about 25 percent of cases of patients with life-limiting illness, the Palliative Care Service takes over primary care duties, often at the request of the physician. The team can devise plans of care and write medical orders. Dahlin and her colleagues often meet jointly with these patients and their physicians to ease any feelings the patient might have about being abandoned by his or her physician.

The continuity of care provided by the palliative care team is a key factor in its success. “We have a policy of continuing to check with patients and families,” Dahlin explains. “The goal is for care to be as seamless as possible from hospital to home or hospice.”

The team dedicates time and effort toward anticipating and preventing problems for patients and families and discussing issues such as advanced care planning, bereavement and other family issues. “We can take whatever time is necessary to deal with problems,” says Dahlin. “We have expertise in pain and symptom control that can be very valuable to the patient. We help people get what they want,” she continues. “We are their advocates.”

The program was easily accepted because its champion, Andy Billings, MD, currently medical director of Palliative Care Service, had a relationship with the hospital as a primary care physician and hospice medical director. The program started slowly, but has grown, both in patient numbers and in case complexity. “We are building relationships, and people are judging us by the care we provide,” says Dahlin, who strives to have a presence on the floor. As Dahlin puts it, she does “curbside consults.”

Dahlin is credentialed to provide consultations at the hospital, at an affiliated rehabilitation facility, in an independent oncology rehabilitation setting and at a nursing home. She bills under Medicare, Medicaid and third-party HMOs. Her salary is divided between the hospital budget and a physician’s group.

Educational Interactions
The Palliative Care Service conducts weekly rounds on issues in end-of-life care and participates in weekly cancer-pain rounds, monthly ALS rounds and occasional oncology rounds. Dahlin and her team also hold weekly palliative care rounds on the oncology floor, psychosocial rounds and nursing rounds.

Dahlin serves as preceptor for graduate and undergraduate nursing students. She also runs two hospital workshops on pain management and palliative care, teaches continuing education courses for students and conducts in-service workshops as needed. “Every interaction is a chance for education,” Dahlin explains, “and you can’t take those opportunities lightly.”

Formal family satisfaction surveys have demonstrated that the Palliative Care Service is appreciated. A clinician survey revealed that the service has been invaluable in difficult situations and has resulted in a quicker transition to less costly therapies. Dahlin’s experience at MGH is testimony to the fact that APNs are an important link in providing care to patients across the continuum of care from the hospital to home.

Personal Reflection
“Being a nurse practitioner in a palliative care role is especially rewarding,” Dahlin notes. “I’m able to work in an advanced practice capacity with all of the expertise that is involved and still use my nursing skills to be attentive to the human needs of my patients. I feel empowered to do whatever is necessary to help patients help themselves at a very critical time in their lives.”

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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