To the Editor:
We read with interest the recent article by Koesel (March 2008) which discussed the positive outcomes of effective communication and symptom management by a palliative care advanced practice nurse (APN) for chronically critically ill (CCI) patients. While Ms Koesel raised several very important issues related to providing care to CCI patients at end of life, we have also noted in our work the very important role that the APN can play in providing communication and support for the caregivers of CCI patients. While the patient in Ms Koesel's article was cognitively intact, we have found that up to 40% of CCI patients are cognitively impaired during their hospital course,1 thus increasing the responsibilities placed upon their caregivers to not only provide support but also play an active role in decision making. We have found that the APN can play a significant role as an advocate for the patient and caregiver in addition to providing information and support.2 This role is particularly important as we (and others) have documented that the caregivers of CCI are at high risk for depression and burden, regardless of where the patient resides.1,3 Finally, Koesel identified that CCI patients and their caregivers are not prepared for poor outcomes and stressed the importance of end-of-life (EOL) care for these patients. We would also add to Ms Koesel's assessment the importance of EOL discussions with the caregivers of CCI patients as well. In a recent study that examined CCI caregiver satisfaction and preparation with EOL care, we found that caregivers identified the importance of being able to talk to the healthcare provider and discuss specific events leading to their loved one's death as key to their satisfaction and preparation with EOL care.4 Thus, while we agree with Ms Koesel that CCI patients benefit greatly from the palliative and EOL care services of an APN, we would also add that the caregivers of these patients benefit as much, if not more, from such a relationship.
Carol G. Kelley, PhD, RN
Assistant Professor
Frances Payne Bolton
School of Nursing
Case Western Reserve University
Cleveland, OH
Sara L. Douglas, PhD, RN
Associate Professor
Frances Payne Bolton
School of Nursing
Case Western Reserve University
Cleveland, OH
Barbara J. Daly, PhD, RN
Professor
Frances Payne Bolton
School of Nursing
Case Western Reserve University
Cleveland, OH
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