1. Drake, Kirsten DNP, RN, NEA-BC, ONC

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Transitioning care between healthcare settings is a current focus for accrediting agencies. According to The Joint Commission, the transition of care denotes the "movement of patients between healthcare practitioners, settings, and home as their condition and care needs change."1 Transition of care as it relates to communication of care across settings has become a core measure for The Joint Commission in specific certification types, such as advanced certification for Comprehensive Stroke Centers, advanced certification in heart failure, and Primary Care Medical Home certification. And the Centers for Medicare and Medicaid Services has incorporated it into stage 2 of Meaningful Use, recognizing communication as being essential for successful care transitions between providers.2,3 Of course, nurses are critical to effective communication at the bedside, identifying patient care goals and supporting patients and their families as they make difficult decisions at the end of life.4

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

How do we define the end of life? The United Kingdom's National Council for Palliative Care designates an individual as entering the end of life when there's an expectation of death within 12 months.5 End-of-life care is defined as the care provided to an individual with an incurable disease so that he or she can experience the best possible quality of life until death.5 This concept isn't isolated to any one area of nursing; however, for the purpose of this article, we'll focus on adult populations and discuss how nurses and nurse leaders in multiple settings can influence patients'-and their families'-end-of-life care transitions.


Ambulatory care

Jane is a 78-year-old widow who visits her primary care provider on an annual basis. She has a history of diabetes and hypertension, which have been maintained by diet and a low-dose angiotensin-converting-enzyme inhibitor. She continues to live independently in the same city as her children. At her visit this year, she has a conversation with her NP: "I've had a few friends pass away this year. I'm scared because my dear friend Marcus had cancer and he got really sick. He was so sick when he went to the hospital that he was eating through a tube and breathing with a machine. I don't think he really would've wanted all of that before he died."


Jane's NP answers: "Jane, I understand your fear. The end of your life doesn't have to be like you described for Marcus. You're still healthy. We can sit down and discuss what you want for when the time comes and you're nearing the end of your life. Today, I'll give you some information to take home and look over, and we'll make an another appointment so we can discuss it further."


A month later, Jane and her son meet with the NP and complete a medical orders for scope of treatment (MOST) form. (See Figure 1.) Jane elects not to have CPR if she stops breathing and her heart stops. She does choose to have limited additional interventions if she's still breathing and has a pulse. She elects to use limited antibiotics and receive I.V. fluids, but doesn't want a feeding tube.

Figure 1:. Sample MO... - Click to enlarge in new windowFigure 1:. Sample MOST form

The end-of-life journey actually begins in the primary care setting. Conversations about advance care planning should start when patients are in a healthier state so that they can clearly communicate their wishes for care, not when they're in crisis. In 1991, medical ethicists in Oregon learned there were inconsistencies honoring patients' wishes at the end of life. Years later, the Physician Orders for Life-Sustaining Treatment (POLST) tool was developed to assist with addressing patient end-of-life preferences. This tool has evolved into the MOST form, which facilitates advance care planning with patients and families by stating actionable details of preferred care, but doesn't replace legal advance directives, such as a do-not-resuscitate (DNR) order. (See Table 1.) However, in some states, such as Idaho, the MOST form has replaced DNR orders.6 Implementation is in various stages of development in each state. Your state's level of development is available at

Table 1: Whats a DNR... - Click to enlarge in new windowTable 1: What's a DNR order?

The POLST/MOST form is completed through collaborative, often lengthy, conversations between the patient and a qualified healthcare provider. The nurse in the ambulatory care setting already has the foundation to participate in these discussions, as well as the capability to educate the patient and his or her family. During these conversations, the nurse must stress the importance of communicating with other healthcare providers about the completed POLST/MOST form.


Acute care

Forward 2 years-Jane is 80 years old and arrives at the ED with symptoms of nausea, vomiting, swelling, and a metallic taste in her mouth. The triage nurse questions Jane about her symptoms and previous healthcare. One of her questions to Jane includes if she has any advance directives or a living will. Jane tells the nurse that she has an advance care plan. The ED nurse makes a copy of the MOST form and puts it on the cover of Jane's chart.


Jane is admitted and transferred to the renal unit with a diagnosis of kidney disease. The nurse on the unit notes the MOST form, reviewing and clarifying with Jane that these are still her wishes for care. Jane agrees and the nurse contacts the hospitalist on the case to obtain orders to match Jane's wishes. The MOST form is also scanned into the electronic health record. Jane is transferred to the telemetry unit for cardiac monitoring. The nurse calling report to the telemetry unit notes that Jane has a DNR order with additional limited medical interventions. The nurse refers the telemetry nurse to the MOST form in Jane's chart for details.


Jane's health improves, but she isn't able to return to an independent living situation at the time of discharge. She's transferred to a long-term-care facility. The care transitions staff member (case manager) is aware of Jane's wishes and looks for facility options that will meet her needs. On the day of discharge, Jane's nurse calls report to the accepting facility and communicates the existing documentation for advance care planning. The nurse also communicates this to the nonemergency transport service personnel.


The onus of multiple care transitions is on acute care providers. These transitions start as the patient enters the hospital at the point of admission and continue through changes in levels of care until the patient is ready for discharge.


Admission to the hospital occurs via primary care settings or the ED. Direct admissions from primary care can offer an opportunity for the accepting staff members to ask the provider if there's any existing advance care planning documents for the patient. The nurse accepting the admission orders should also inquire if the patient has a previous out-of-hospital DNR order; if so, then an inpatient DNR should be obtained. The reason for admission is significant: the patient is either coming from a setting that can no longer care for him or her, it's the patient's preference, or the patient is experiencing complications.7


More admissions occur through the ED than directly from ambulatory care settings. As patients arrive in the ED, nurses and other healthcare providers don't always have the time to assess a patient's advance care planning status and they're often unable to obtain a full history from the patient or family. In the event that the patient arrives via ambulance, the nurse can ask emergency medical services (EMS) staff about the patient's code status and other advance care planning preferences. However, this is based on the assumption that the EMS personnel have access to the information. Patients arriving to the hospital via ambulance from a postacute care setting should already have their wishes documented. If the patient's preferences aren't known, the ED staff will begin interventions.


Once admitted to the inpatient setting, the patient may experience numerous transfers among units based on the level of care needed. If the patient is receiving aggressive treatment, he or she will inevitably transfer to the ICU. The ICU nursing staff members then need to have crucial conversations with the patient's family. The ICU is a location where end-of-life care discussions begin if the patient is experiencing a life-threatening illness or traumatic event. It's vital for ICU nurses to be skilled in communication related to the end of life or have access to trained staff members who can initiate these conversations. Nursing staff members trained to have end-of-life care discussions are frequently those who work in palliative care.


Understandably, not all hospitals have an established palliative care program; however, there are courses available through the American Association of College of Nursing's (AACN) End-of-Life Nursing Education Consortium (ELNEC) to assist with training.8 The ELNEC program consists of a core curriculum, as well as specialty programs for ICU, geriatrics, and pediatrics, and can be accessed through a classroom setting or online. Educational material is related to physical symptoms, cultural and spiritual concerns, ethical concerns, and communication.


The transfer of information to the next level of care on the general unit is critical. Adequate and thorough handoffs are fundamental to ensure that appropriate end-of-life care continues for the patient. The Joint Commission's Transitions of Care Portal has several tools to assist with handoff and education for staff.1 These handoff tools provide an avenue to transfer information consistently to other providers taking over care.


The patient's last transition from the hospital is discharge to a postacute care setting. Discharge is an important aspect of care continuity after hospitalization and can contribute to the prevention of readmission. There are several models available to assist with successful transitions at discharge. One model is the use of a discharge planner, care coordinator, or care transitions manager. The titles and duties of these personnel can vary, but their main focus is getting the patient to the correct level of care and communicating with providers in the new environment.9 Another initiative is the use of a clinical nurse leader-an AACN certification that includes care transitions as a competency.10,11 Remember that having these roles in place doesn't negate the use of interdisciplinary rounds during which the team gathers to discuss the patient's care preferences.


The process of transitioning a patient at discharge may not require an added full-time equivalent. Implementing tools through the electronic health record system can allow for communication with care providers outside of the hospital. Another option to continue communication at discharge regarding end-of-life care is the initiation of the Vial of Life Project.12 This program provides a mechanism of communication to EMS staff about the patient's history, medication, and advance care planning. In cases where the family is panicked and unable to answer questions clearly, the EMS personnel will have the needed documents to provide the desired care.


There are multiple facets to transitioning a patient from the hospital to another level of care. Assessing your organization's discharge process through programs such as Better Outcomes by Optimizing Safe Transitions, or BOOST, will provide information regarding opportunities for improvement.13 The BOOST toolkit also offers interventions to enhance the discharge process.


Postacute care

Upon Jane's arrival to the long-term-care facility, the admitting nurse reviews the MOST form. She clarifies with Jane that these are still her wishes. At this time, Jane decides to change one of her requests from limited additional interventions to comfort care measures. (See Table 2.) The nurse communicates these wishes to the admitting physician and Jane's advance care plan orders are changed. Jane acquires an infection while at the facility and receives antibiotics as outlined in her advance care plan.

Table 2: The importa... - Click to enlarge in new windowTable 2: The importance of palliative care

Patients at the end of life transfer to postacute settings, including long-term-care facilities, hospices, or back home. Postacute care providers must continue to follow the patient's preferences, inquiring about them before he or she is accepted to their facility. Again, if end-of-life care preferences aren't clear, the postacute care provider can initiate the POLST/MOST form. If the patient's preference isn't to go back to the acute care setting, the provider needs to make all efforts to meet this wish. To facilitate this, quality improvement initiatives for long-term-care facilities, such as Interventions to Reduce Acute Care Transfers (INTERACT), have been developed.14 Programs such as INTERACT focus on early identification of status changes so that the patient may receive treatment without changing environments. The INTERACT program also offers order sets to address specific patient desires to provide early assessment and interventions to avoid hospitalization.


The nurse leader's role

The bottom line is that the nurse leader's role in supporting care coordination and care transitions at the end of life is imperative. The American Organization of Nurse Executives and the American Academy of Ambulatory Care Nursing have identified six principles to guide nurse leaders in this role:15


* know how care is coordinated in your setting


* know who's providing care


* establish relationships with multiple entities and individuals who can work together to improve care coordination and transition management systems


* know the value of technology, its impact on workflow, and the roles of care coordination team members


* engage the patient and family


* engage all team members in care coordination.



A key point when applying these principles is communication of the patient's end-of-life preferences. Focusing on tasks may well take precedence for nursing staff; however, nurse leaders can provide nurses with education about how to communicate during care transitions at the end of life.


Communication at the center

Although Jane did become septic while living at the long-term-care facility, she was able to stay at the facility and receive comfort care measures. This was made possible as a result of the healthcare providers being diligent in the communication of her documented advance care planning, allowing Jane to die peacefully and comfortably with her family by her side.


Jane's experience isn't typical in our healthcare environment. Communication often doesn't flow flawlessly when it comes to the patient's desires and wishes at the end of life. Nurse leaders can work to keep the patient at the epicenter so that every transition in his or her journey is as smooth as Jane's final experience.


INSTRUCTIONS Care transitions at the end of life



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2. The Joint Commission. Transitions of care: the need for a more effective approach to continuing patient care. [Context Link]


3. Centers for Medicare and Medicaid Services. Stage 2 eligible professional meaningful use core measures. [Context Link]


4. Malloy P, Virani R, Kelly K, Munvevar C. Beyond bad news: communication skills of nurses in palliative care. J Hospice Palliative Care. 2010;12(3):166-174. [Context Link]


5. National Council for Palliative Care. Commissioning end of life care. [Context Link]


6. Idaho Emergency Medical Services. Physician orders for scope of treatment. [Context Link]


7. Cohen J. Hospital admissions at the end of life: reasons, appropriateness and avoidability. [Context Link]


8. American Association of Colleges of Nursing website. End-of-life nursing education consortium. [Context Link]


9. Naylor M, Keating S. Transitional care: moving patients from one care setting to another. Am J Nurs. 2008;108(9):58-63. [Context Link]


10. Commission on Nurse Certification. Certified clinical nurse leader talking points. [Context Link]


11. American Association of Colleges of Nursing. Competencies and curricular expectations for clinical nurse leader education and practice. [Context Link]


12. Vial of Life Project. [Context Link]


13. Society of Hospital Medicine. Project BOOST implementation toolkit. [Context Link]


14. Florida Atlantic University. Interventions to reduce acute care transfers. [Context Link]


15. American Organization of Nurse Executives. Joint statement: the role of the nurse leader in care coordination and transition management across the health care continuum. [Context Link]


16. Center to Advance Palliative Care. Definition of palliative care.