Integration of Palliative Care Screening Tools for End-Stage Liver Patients to Improve End-of-Life Care.

Liver disease is often associated with high symptom burden and long hospital stay, leading to a decreased quality of life. For patients considered unsuitable for transplantation, the alternative treatment options are supportive management and palliative care (PC). The most significant barrier to early PC is the failure to identify patients who may benefit from it. Currently, transplant healthcare professionals have limited PC education as well as a limited understanding of primary PC and PC service flow. The purpose of this quality improvement (QI) project is to identify nontransplantable liver disease (NTLD) patients' unidentified unmet PC needs, utilizing two validated tools Necesidades Paliativas Palliative Needs (NECPAL) and Chronic Liver Disease Questionnaire (CLDQ), and integrate them within routine nursing care activities in the transplant unit to increase pain and symptom management. This Doctor of Nursing Practice (DNP) project was integrated into a QI project over 12 weeks in the Fall of 2019. Transplant nurses and nurse practitioners (NPs) completed the tools for every NTLD patient to identify patients in need of PC and to assist identification of end-of-life symptoms to determine the quality of life. A total of 5 NPs and 10 staff nurses received education and training on the NECPAL and CLDQ tools from the DNP project leader. Sixteen nontransplant liver disease patients, aged 29-68 years, median age of 52 years, majority being (69%) female, participated. The percentage of patients who completed the CLDQ and reported symptoms of unmet needs was an average of 80%. The most common symptoms reported were abdominal bloating and discomfort, worrying, and family impact. The goal was for all nurses and NPs to complete the screen tool 100% of the time. The percentage of patients completing the NECPAL, at an average of 60%, indicated a need for integrating PC. Implementation of NECPAL and CLDQ tools identified multiple unmet PC needs in NTLD patients. Nurses and NPs reported the tool was easy to use in identifying symptoms and clinical indicators for the identification of unmet PC needs and to promote incorporation into routine nursing care in liver disease patients who were deemed nontransplantable and allowed nurses to advocate for symptom and pain management with objective validated tools. The NECPAL and CLDQ screening tools can identify clinical symptoms and the need for integration of PC. Incorporating PC needs promotes optimal end-stage quality of life for patients and their families. Ongoing training for NPs and nursing staff is needed to continue providing identification of patient PC needs. These nurse-initiated screening PC tools can be easily implemented in other units caring for patients with chronic and/or end-stage diseases to improve symptom management and end-of-life care.