Palliative Care Nursing: Interview with Craig Raclawski, RN
Providing end-of-life education, resources and compassionate care
Please share with us a little about your life and nursing career.
In my life, I have been incredibly fortunate in having had two professions. My first chapter was as an international ballet dancer, which offered me a transglobal immersion in human emotion and the power of interaction. This colorful and dynamic exposure gave me a base for my second profession as a nurse, understanding and guiding patients from many cultures to gracefully express their eminent wishes.
After graduating from nursing school in 1998, my first chosen specialty was within the cardiothoracic arena, where I was initially exposed to the chronic and underrepresented needs of the intensive care and critically ill patient.
What sparked your interest in end-of-life and palliative care?
Prior to my clinical experience, I was the caregiver for a good friend who was suffering from HIV and eventually died from AIDS. This was before there was an antiretroviral drug cocktail or any of the current medical treatments to assist in living with this disease. This was a formative event that led to my current professional choice. I immersed myself as a volunteer for Project Nightlight, which helped me understand how to support someone in the process of dying. Helping my friend navigate his illness confirmed that nursing would be a very rewarding life choice.
How did you become the palliative care coordinator at Glendale Memorial?
Frequently, patient, family and medical systems do not coexist seamlessly with impending death. I’ve been fortunate to be part of Glendale Memorial Hospital for over eight years, working with critically ill patients and their loved ones. My past and present experiences have allowed me to integrate the spiritual and physiological needs that allow the critical patient to gracefully transition to their next phase.
Glendale Memorial Hospital had a social worker who was involved in starting our palliative care initiative along with Dr. Douglas A. Webber, our physician champion. They wanted a full-time nursing position in this program and were looking to bring inpatient palliative care to this facility.
Before I took the position of palliative care coordinator, a group of ICU nurses from Glendale took part in specific training with ELNEC, the End-of-Life Nursing Education Consortium. This training is sponsored by City of Hope and was led by Betty Ferrell, the “godmother” of palliative care.
The training was a two-day workshop that really elucidated the practices of palliative care, pain management, symptom management, loss and grief and the ethical, cultural, communications and spiritual issues surrounding the dying process. This was my first concentrated and formalized certificate training in palliative care.
When did the program begin?
In June of 2011, the program opened, and we began seeing patients in September of that year. The Center to Advance Palliative Care came down in October and provided intensive training for the interdisciplinary team, which included the physician, social worker, nurse, chaplain, speech therapist and administration. This allowed us to enter the space of a communal, interdisciplinary process.
Do you have a dedicated palliative care unit at Glendale?
No, we don’t at this time. Our team functions like any other consulting service in the hospital and we can see patients on any unit. The attending physician must ask for a palliative care consult. Our job is to assess the patient and make our recommendations.
There are screening assessments performed by the primary nurse in the ICU to trigger evaluation by the PC team. This assessment prompts our evaluation and also serves as an education opportunity for the primary nurse to view the patient holistically along their continuum of care.
Once we evaluate the patient, we request a consult by communicating to the physician our ability to provide the patient with services that may include psychosocial and spiritual support, goal clarification, advanced care planning, code status and advanced directives, as well as pain and symptom management.
In my role, I serve more or less as an independent agent. I come to work each morning, review PC screening referrals house-wide and review patients in the ICU by taking part in interdisciplinary ICU rounds. This gives me the daily opportunity to educate the interdisciplinary team at the bedside.
How does the transition to hospice happen?
In our facility, the physician writes the order for a hospice evaluation. We use the physician order for life-sustaining treatment (POLST) form, which follows the patient and was developed by the California Commission for Compassionate Care. I believe facilities on the East Coast use the MOLST form, which stands for medical order for life-sustaining treatment.
The transition would include identifying three categories of POLST that walk us through the conversation: full treatment, limited interventions and comfort measures only.
Good palliative care is about problem-solving, finding solutions and creating a win-win for the patient and the medical team. This all begins with conversations that are crucial to the process. I believe you must give patients detailed, correct information about resuscitation and heroic measures and assist the patient in identifying their goals for a desired quality of life and good death as part of an honest dialogue. Then, they are able to determine whether hospice is the right choice for them.
Most physicians and nurses are not comfortable with this crucial conversation in such tender territory.
Please share with us the challenges of your specialty area.
I’m not specifically challenged by being saturated with death and dying. I’m more spiritually grounded since taking on this role. I do yoga, get centered and leave this stuff at work or on the yoga mat. I attend church and have found other ways to balance my life, which is always a work in progress — like it is for most of us.
Honestly, healthcare is changing and, as somebody said the other day, if you can’t flow with change, this is not a profession to remain in. We must be mindful of current financial/fiscal restraints and programs, government and private sector, that may affect our day-to-day function and the ways in which we operate. One challenge is that there are more and more incentives to keep patients out of the hospital and currently there is no recognized model for outpatient palliative care.
Another challenge is that palliative care reimbursement is not as clearly understood as hospice and acute care billing. While there’s no cost for me to see the patient, a PC physician does bill for his or her services. Some physicians are unclear on the role of the PC physician and may fear that he or she will now assume primary care, thus ending the reimbursement of the original physician.
What feeds your spirit and keeps you coming back?
In the beginning, it was death and dying that brought me into nursing, so I have found a true passion for myself. Death, like birth, is a monumental time to be involved in someone’s life. It’s an honor to help someone write their final chapter.
You won an award in 2012. Can you tell us about that?
I won the Southern California Cancer Pain Initiative Excellence in Pain Management Award. It was a great honor to be recognized for the work I care so much about.
Are there certifications or trainings that are recommended for this specialty?
I would recommend the POLST, ELNEC and POLST “train the trainer” programs. The HPNA (Hospice and Palliative Nursing Association) also offers the CHPN (Certified Hospice and Palliative Nurse) credential, which is wonderful to achieve.
Do you belong to any specialty organizations?
I’m a member of the HPNA, including our local chapter. I also belong to the Greater Pasadena Area POLST Coalition and serve as a member of the Glendale Memorial Hospital Bioethics Committee.
Can you share a story about your work that illustrates what you love about it?
Once, while I was working in ICU, this elderly man had a stroke and was extremely incapacitated. He had no blood family, but many, many friends. I helped them figure out the steps to determine his goals and find his advanced directive paperwork.
This gentleman had an amazing passage. He previously ran an open mic night in town and friends came to his room to share stories of his life. There was music, laughter and tears in that room, and he was surrounded in such a loving way. That single event reminded me why I am here.
Keith Carlson, RN, BSN, has worked as a nurse since 1996 and has maintained the popular nursing blog Digital Doorway since 2005. He offers expert professional coaching for nurses and nursing students at www.nursekeith.com.
This article is from workingnurse.com.