am feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients'

Two nurse leaders offer their top tips

1. Set up routine processes and algorithms so nurses can more easily make decisions about treating immediate patient needs.

The most effective nurses are the best-supported nurses. Providing proper training and developing routine processes and algorithms empower nurses to make decisions about treatment when appropriate. Opportunities for quick physician consultation also provides nurses with the support they need.

At Mount Carmel Health System, nurses interact with physicians five days a week in daily rounds. There are weekly interdisciplinary team meetings that further strengthen this interdisciplinary collaboration. At the meetings, the team discusses cases in more detail, shares information, solves problems and learns from each member. A palliative care physician is on-call 24 hours per day, seven days per week.

At Massey Cancer Center, there are 18 evidence-based algorithms in place which are reviewed every year and approved by the attending physicians for palliative care patients on our unit. Trained nurses on the unit can use the algorithms to promptly treat dsypnea, anxiety or pain, for example, which makes them better able to respond quickly to patient and family needs. Patients get immediate treatment and positive outcomes without needing to wait for the doctor. The nursing staff knows they are giving the right treatment in a timely fashion.

2. Create a culture of flexibility and responsiveness to patient needs.

Even with good processes and procedures in place, there may be uncertainty and gray areas. For instance, understanding a patient's goals of care can be time consuming and complex. However, these conversations are critical to providing appropriate care. By focusing on and setting a patient's goals of care, it's much easier to know how to proceed. If you're wondering whether to draw a lab on a patient or provide antibiotics to an elderly person with aspiration pneumonia, there is no right or wrong textbook answer. The answers should be determined by whether these actions meet the goals of care.

Guidelines in a unit or on a service are necessary, but they should not be viewed as hard and fast rules. Here are two cases from Massey Cancer Center to illustrate the point:

• Massey Cancer Center doesn't usually allow overnight visits by children, but a nine-year-old slept with his mom on the unit two days before she died. That was the right thing to do in that situation.

• In another case, Massey Cancer Center made an exception to the usual rule of extubation before transfer to the unit. The case involved a 38-year-old father from the ICU who'd been in a motor vehicle accident. The ICU team feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients' m

t the meetings, the team discusses cases in more detail, shares information, solves problems and learns from each member. A palliative care physician is on-call 24 hours per day, seven days per week.

At Massey Cancer Center, there are 18 evidence-based algorithms in place which are reviewed every year and approved by the attending physicians for palliative care patients on our unit. Trained nurses on the unit can use the algorithms to promptly treat dsypnea, anxiety or pain, for example, which makes them better able to respond quickly to patient and family needs. Patients get immediate treatment and positive outcomes without needing to wait for the doctor. The nursing staff knows they are giving the right treatment in a timely fashion.

2. Create a culture of flexibility and responsiveness to patient needs.

Even with good processes and procedures in place, there may be uncertainty and gray areas. For instance, understanding a patient's goals of care can be time consuming and complex. However, these conversations are critical to providing appropriate care. By focusing on and setting a patient's goals of care, it's much easier to know how to proceed. If you're wondering whether to draw a lab on a patient or provide antibiotics to an elderly person with aspiration pneumonia, there is no right or wrong textbook answer. The answers should be determined by whether these actions meet the goals of care.

Guidelines in a unit or on a service are necessary, but they should not be viewed as hard and fast rules. Here are two cases from Massey Cancer Center to illustrate the point:

• Massey Cancer Center doesn't usually allow overnight visits by children, but a nine-year-old slept with his mom on the unit two days before she died. That was the right thing to do in that situation.

• In another case, Massey Cancer Center made an exception to the usual rule of extubation before transfer to the unit. The case involved a 38-year-old father from the ICU who'd been in a motor vehicle accident. The ICU team feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients'

taff knows they are giving the right treatment in a timely fashion.

2. Create a culture of flexibility and responsiveness to patient needs.

Even with good processes and procedures in place, there may be uncertainty and gray areas. For instance, understanding a patient's goals of care can be time consuming and complex. However, these conversations are critical to providing appropriate care. By focusing on and setting a patient's goals of care, it's much easier to know how to proceed. If you're wondering whether to draw a lab on a patient or provide antibiotics to an elderly person with aspiration pneumonia, there is no right or wrong textbook answer. The answers should be determined by whether these actions meet the goals of care.

Guidelines in a unit or on a service are necessary, but they should not be viewed as hard and fast rules. Here are two cases from Massey Cancer Center to illustrate the point:

• Massey Cancer Center doesn't usually allow overnight visits by children, but a nine-year-old slept with his mom on the unit two days before she died. That was the right thing to do in that situation.

• In another case, Massey Cancer Center made an exception to the usual rule of extubation before transfer to the unit. The case involved a 38-year-old father from the ICU who'd been in a motor vehicle accident. The ICU team feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients'

uld be determined by whether these actions meet the goals of care.

Guidelines in a unit or on a service are necessary, but they should not be viewed as hard and fast rules. Here are two cases from Massey Cancer Center to illustrate the point:

• Massey Cancer Center doesn't usually allow overnight visits by children, but a nine-year-old slept with his mom on the unit two days before she died. That was the right thing to do in that situation.

• In another case, Massey Cancer Center made an exception to the usual rule of extubation before transfer to the unit. The case involved a 38-year-old father from the ICU who'd been in a motor vehicle accident. The ICU team feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients'

am feared that he might die immediately from removal of the tube. By leaving it in, he had 24 hours in a supportive environment with his wife and daughter.

3. Think beyond hospital walls to the broader continuum of care.

Hospitals need to think beyond their own walls when devising a good palliative care plan for a patient. Nurses should ask, "What is realistic in terms of caregiving, finances and outcomes outside the hospital?" Patients and families need education on their options. Build those outside options and agencies into the plan of care, and communicate with receiving agencies. In order to ensure an orderly transition from one setting to another, patients' medical information and reports should be sent to the appropriate outside agencies.

4. Build in a support structure of nursing staff to prevent burnout.

An improperly structured palliative care team can lead to nurse burnout. It is critical to have adequate staffing and an interdisciplinary team with a high degree of collaboration to help mitigate burnout. The support and collaboration of the interdisciplinary team alleviates the perception by nurses who often think and feel they are saving the world by themselves.

Prepare staff through education and training. Teach staff communication skills and how to have difficult conversations. Providing the appropriate tools nurses need to take care of patients greatly impacts the ability for them to continue their work.

Obtain administrative buy-in and support. When leaders in the organization value what nurses are doing there is a sense of esprit de corps among the staff. When all staff is doing the same thing - giving the right care at the same time - it is rewarding and people feel a sense of connection and purpose, which improves retention and reduces burnout.

At Massey Cancer Center, an annual memorial service with family members is a very rewarding event for everyone. They also hold an annual staff retreat where the interdisciplinary team spends a day off the unit, further developing relationships and team building. The best services are those with a close-knit group of nurses who look out for each other. Encourage nurses to use their vacation time and make it easy for them to take it when they need it. Help them find sources of relaxation. The chaos of the average day can be hard, so it's important to get mental and emotional breaks.

To view the algorithms, go to http://www.capc.org/signup (E-mail address registration required to access tools.)