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Item The nurse practitioner's perspective of the physician orders for life-sustaining treatment (POLST) form(Montana State University - Bozeman, College of Nursing, 2020) McAllister, Sarah Elizabeth; Chairperson, Graduate Committee: Stacy StellflugThe assessment, documentation, and implementation of a Physician Orders for Life-Sustaining Treatment (POLST) form are important for end-of-life care. As primary care providers, nurse practitioners have an important role in advanced-care planning, including the completion of POLST forms (Hayes et al., 2017). The purpose of this project was to better understand the self-reported practices and opinions of nurse practitioners as they assist patients in completing the form. The project was a partial needs assessment to inform later quality improvement (QI) work and used a survey design to assess and gain better understanding of the practices and opinions of nurse practitioners with the POLST form. Questions 1, 4, 6, and 8 were 'select all that apply' and Questions 2, 5, 7, and 9 required a single response. A total of 126 surveys were sent out with a response rate of 39.6%. Overall, nurse practitioners in Billings, Montana, were familiar with the POLST form (n=45, 90%). Half (n=28, 50%) of the nurse practitioners surveyed used the POLST form in their clinical practice despite having barriers to its completion such as it being time consuming (n=18, 25.7%). Over half (n=45, 60.0%) of the nurse practitioners surveyed believed that the most appropriate time to complete the POLST form was after a provider (any provider) discusses goals of care and medical treatments with the patient and/or family. Although some nurse practitioner respondents had no concerns with completing the POLST form (n=12, 21.1%), 21 of the respondents (n=21, 36.8%) reported issues regarding the understandability of the form for patients and/or families. Survey results showed familiarity of the POLST form is not a barrier to its completion in Billings, Montana, but 25.7% of the respondents believed the time it takes to complete the form was a barrier to completing it with patients and/or families. Nurse practitioners could include extra time in appointments or use annual wellness visits to discuss goals of care with patients and/or families. Future effort could also focus on reducing the amount of time nurse practitioners spend filling out a POLST form accurately and completely with their patients and/or families.Item The attitudes of nurses involved in standardized inpatient comfort care: a pilot study(Montana State University - Bozeman, College of Nursing, 2017) Waldorf, Jamie Elizabeth; Chairperson, Graduate Committee: Jennifer SofieThis paper explores nurses' perceptions and attitudes utilizing a standard inpatient comfort-care order set in a critical-access hospital in Southwestern Montana. Comfort care is a subset of palliative care and has been defined as 'an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person's wishes' (National Institute on Aging, 2012). With past research showing gaps in continuity of care for patients requiring palliative and comfort care, standardizing the care will give each patient nearing the end of their life, and their family, the opportunity for the best care. A pre- and post-trial-implementation qualitative survey was utilized with the nursing staff at this facility in order to identify areas of weakness with comfort care, and how these weaknesses could be addressed. Initial results showed that nurses felt that more education to both providers and nurses and standardizing care would lead to the most benefit for overall patient care. Providers at this facility worked together to build a standing order set utilizing The BEACON project from the Veterans Affairs (VA) department as well as the order set that was already in the electronic medical record system in order to build one order set that would work best for this facility. Providers and nurses were educated on how to use this order set, as well as the standards of care for nursing. Post-implementation nursing surveys showed that nurses were overall more satisfied with the care they were giving to patients near the end of life, and that they felt the order set was successful in setting the standard of care. Nurses also felt that, by receiving more education in the area of comfort care, this opened the lines of communication between staff members, thus improving patient care.Item Respecting end of life wishes: development and implementation of an evidence-based intervention to increase the completion of advance directives(Montana State University - Bozeman, College of Nursing, 2017) Fanelli, Christine Marie; Chairperson, Graduate Committee: Jennifer SofieWith an aging population and medical advancements people are living longer. With advanced age often come chronic conditions making it increasingly important to communicate end of life (EOL) care preferences to family, loved ones, and healthcare providers. However, despite the proven benefits that advance care planning (ACP) can provide for patients, families, and providers, it remains a challenge to initiate such conversations and advance directive (AD) completion rates remain low. The purpose of this project was to analyze the current process of discussing EOL care preferences, completing and accessing ADs in a rural family practice clinic and identify areas in need of improvement. The primary goal is to increase completion of ADs with a secondary aim to increase healthcare provider accessibility to ADs. Development and implementation of an ACP intervention consisting of a standard visit for a provider initiated ACP discussion with patients 65 years and older. Pre and post AD knowledge surveys before and after the visit, augmented with a census medical record review (MRR) were used to evaluate the intervention. A total of 26 patients, 4.42% of the eligible population chose to participate. The project found that the majority 69.23% (n=18) of the participants reported having an AD, however 55.56% (n=10) were not documented in the EMR. Further, 37.50% (3) of participants reported not having one but was found to have had a Physician Orders for Life Sustaining Treatment (POLST) during both pre and post intervention periods. The MMR found 81.72% (n= 733) of patients from both time periods did not have an AD in their electronic medical record (EMR). None of the intervention participants were found to have completed an AD following the intervention, however, it proved to be informative and somewhat influential on their thoughts surrounding EOL preferences and discussing them with others. The intervention had no effect on the completion of ADs as reflected by the proportion of ADs found in the EMR in the post intervention period. In fact, the proportion of ADs found in this period decreased. Overall, the intervention was beneficial as it further identified challenges in the current process recognizing provider accessibility to ADs as the bigger issue as well as the need for additional patient and provider education.Item A study of extraordinary means in relation to the aged, the critically ill, and the dying(Montana State University - Bozeman, College of Professional Schools, 1971) Maiers, Mary Gerals, SisterItem The effect of an educational intervention on improving acute care nurses' level of knowledge in providing high quality end-of-life care to patients with less than 2 weeks to live(Montana State University - Bozeman, College of Nursing, 2016) Stetzner, Katelyn Jo; Chairperson, Graduate Committee: Christina SieloffAlthough nurses, above all other health professionals, are in a prime position to positively impact the quality of end-of-life care (EOLC) individuals receive, numerous studies have identified that they are educationally unprepared to do so (White & Coyne, 2011). The purpose of this study was to determine the effect of an educational intervention on improving acute care nurses' level of knowledge regarding high quality EOLC to adult patients who are preactively and actively dying (i.e., deemed to have less than 2 weeks to live). Because "EOLC in the acute setting frequently takes place over a very short time frame when death is recognizably imminent" (Bloomer et al., 2011, p. 167), the researcher focused on the preactive and active phases of dying and the nursing interventions necessary to provide quality EOLC to patients during their final days and hours of life. The researcher explored the acute care nurses' level of EOLC knowledge, implemented an evidence-based educational intervention using the ELNEC-Core curriculum (COH & AACN, 2000), and determined whether the educational intervention successfully improved the nurses' level of knowledge in providing quality EOLC to adult patients with less than 2 weeks to live. A one-group pretest--posttest research design was implemented to test the hypothesis: Upon completion of the educational intervention the acute care nurse participants will achieve significantly higher scores on the posttest than they do on the pretest. Thirty-one acute care RNs and LPNs voluntarily participated in the study. Data were collected and stored by the software vendor in such a way that data were available only in the aggregate form for each item. Therefore, no direct pretest--posttest comparisons could be made for the individual participants. As a result, descriptive analyses were utilized to examine and report the findings of the participants' aggregate pretest and posttest results. As hypothesized, participants' answered more questions correctly on the posttest than they did on the pretest. Whereas such results could not be directly attributed to the educational intervention, the findings suggest that the participants, as a whole, possessed a higher level of EOL knowledge at the completion of the study.Item Experiences of loss and grief among hospital nurses(Montana State University - Bozeman, College of Nursing, 1985) Kelly, Jo ThorsonItem Discussing end-of-life care in the emergency department : to attempt resuscitation or allow a natural death(Montana State University - Bozeman, College of Nursing, 2014) Kelly, Catherine Grace; Chairperson, Graduate Committee: Dale MayerPatients on a known dying trajectory quite frequently present to the emergency department (ED), unprepared for some of the common and inevitable crises related to their disease process, and most of them have not prepared an advance directive. Near end-of-life (EOL) patients who present to the ED with an emergent need for symptom management may instead be faced with an incongruent treatment plan focused on lifesaving interventions. Time constraints, lack of prior patient-provider relationship, vague and misleading terminology, and patient misconceptions about attempted resuscitation interfere with discussions about EOL care preferences in the ED. Questions sometimes posed by ED providers such as "If your heart stops beating, do you want us to try and start it again?" or "If you stop breathing, do you want us to put in a breathing tube?" or the more loaded question "Do you want us to do everything?" are problematic because patients are offered no tangible alternatives; in essence, the choice they are presented with is between doing everything and doing nothing. Realistically, who will choose nothing? There is a growing movement toward using more precise language to discuss attempted resuscitation and allowing natural death. The purpose of this project was to explore the language used during patient-provider conversations about attempted resuscitation versus allowing natural death. A case study was used to interview emergency department physicians, nurse practitioners, and physician assistants. Twelve topics emerged during the interviews regarding how providers discuss attempted resuscitation versus allowing a natural death. The interviews revealed areas where patient-provider communication may be improved, and highlighted the need to replace ambiguous language with more frank and detailed discussions of EOL care options. ED providers need to become more comfortable discussing EOL care, and give patients and families the full benefit of making informed decisions in line with their goals of care.