Nurse Practitioner

special interest group newsletter

Volume 25, Issue 1, April 2014
Coordinator’s Message:
SIG to Meet and Network During Congress

Tamika Turner, MS, NP-C, AOCNP®
Indianapolis, IN

ONS’s 39th Annual Congress is being held this year in Anaheim, CA, from May 1–4. The schedule posted online has a great feature that highlights the sessions particularly suited for advanced practice nurses. Because of member feedback from last year, we will not have a guest speaker but rather use the opportunity for a brief meeting and networking session. Please join us if you are able to on Friday, May 2, at 9:45 am in the Learning Hall, Theater 2.

I encourage you to visit the Nurse Practitioner SIG’s Virtual Community (VC). We will have a brief demonstration at our SIG meeting at Congress covering access and navigation of the VC. On the VC, you will find upcoming meeting dates, educational offerings, legislative updates, and our discussion board.

As always, we are looking for articles—even very short articles—to share in our newsletter.

Please let me or Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®, know of your interest and we can help bring your ideas to the other NP SIG members. Many of you may be working on a Doctor of Nursing Practice. Recycle those papers you are writing for class into an interesting article for our newsletter. We welcome all ideas.

The Nurse Practitioner SIG Newsletter is produced by members of the
Nurse Practitioner SIG and ONS staff and is not a peer-reviewed publication.

Nurse Practitioner

Special Interest Group Newsletter  April 2014

Use of the Emergency Department for Patients With Advanced Cancer at the End of Life

Kathleen Slavish, MPH
Pittsburgh, PA

Michael Beach, DNP, ACNP
Pittsburgh, PA

Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Sewickley, PA

The emergency department is a critical site of care delivery and a safety net of the acutely and chronically ill. Emergency departments in the United States increasingly are utilized by patients with cancer for disease- or treatment-related problems. Particularly, patients with advanced and end-stage disease in need of symptom management and pain relief present to the emergency department due to symptoms that are out of control, a new onset of a frightening sign or symptom, or a misunderstanding regarding self-care issues. Despite these important functions, the emergency department is a risk and burden for patients with cancer due to the vulnerability for infection, limited time for the clinicians to review the extensive past medical history of many patients with advanced cancer, and expense of this care. Undergoing the anxiety and cost of emergency department visits is not ideal for patients with advanced cancer and their families (Rosenberg & Rosenberg, 2013). Understanding reasons for and outcomes of emergency department utilization for patients with cancer is important in improving the quality of care.

Deborah Mayer, PhD, a nurse researcher at Duke University in Durham, NC, led a study exploring the reasons for emergency department utilization among patients with all stages of cancer in North Carolina. They found that most patients had just one visit, and the three most commonly cited reasons for emergency department visits were pain, respiratory distress, and gastrointestinal issues. A full 63.2% of emergency department visits resulted in hospital admittance (Mayer, Travers, Wyss, Leak, & Waller, 2011). Patients with lung cancer were more likely to be admitted than patients with other types of cancer.

An analysis in Great Britain of the utilization of after-hours primary care centers found pain to be the most common presenting symptom (Barbera, Taylor, & Dudgeon, 2010). The pain was severe for patients already prescribed opiate medication. Emergency department visits seem to increase with more advanced-stage cancer.

In a small study (n = 100) of women with advanced breast cancer who died between 2010 and 2012 at a large urban breast cancer center, emergency department visits were very common (Slavish, 2013). Sixty-nine percent (n = 69) of patients had documentation of emergency department utilization in the last six months of life, accounting for a total of 190 visits, or 2.8 ± 1.7 visits per patient (Slavish, 2013). For these patients with more advanced-stage cancer, 73% (n = 138) of the emergency department visits resulted in admission to the hospital, with cardiopulmonary reasons, most often shortness of breath, contributing to the majority of hospitalizations (Slavish, 2013).

Interventions to reduce the incidence of emergency department care by patients with cancer are emerging. One of the interventions may be the integration of palliative care into metastatic care visits. Bakitis et al. (2004) utilized supportive palliative care education in metastatic cancer care and did find better quality of life but did not find a reduction in emergency department use among patients with end-stage cancer as compared to usual care. Temel et al. (2010) did find that integrated palliative care in patients with advanced-stage lung cancer not only resulted in less distress but also reduced emergency department utilization.

Many questions remain. Could the number of disruptive and costly emergency department visits be decreased with better planning, education, or proactive counseling? These questions have important implications for nurse practitioners in cancer care. A workgroup session at the 2009 Agency for Healthcare Research and Quality/American College of Emergency Physicians conference “Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach,” led to the development of four key research questions. These questions include the following.

  • Which patients are in greatest need?
  • What is the optimal role of emergency clinicians in caring for patients with cancer or advanced cancer?
  • How does the integration and initiation of palliative care training and services in the emergency department setting affect healthcare utilization?
  • What are the educational priorities for emergency clinical providers in the domain of palliative care?

A wide range of research methodologies were proposed to answer these questions.
The conference consensus statement (Quest, Asplin, Cairns, Hwang, & Pines, 2011) acknowledged the difficulty of integrating palliative care into emergency department culture. The group felt that a model for the integration of palliative care for patients with cancer in the emergency department could be addressing other “health-promoting” issues, ones not thought to be part of emergency department care but now commonly assessed as components of good care. Routine assessment of tobacco use, alcohol consumption, seatbelt use, domestic violence, and firearm safety is now considered to be not only good patient care, but also beneficial to national healthcare outcomes. Routine questions about end-of-life directives with palliative care consultations initiated in emergency department admission orders may transform the emergency department visit into a conversation catalyst regarding end-of-life wishes.

Nurse practitioners in cancer care may decrease these emergency department visits through two mechanisms. The first is proactive education or anticipatory guidance preparing patients and their families for likely symptoms with education and management strategies, including likely needed prescriptions or home care durable goods. This often requires coordination with home care or other supportive services. The other intervention that nurse practitioners in cancer care may initiate, probably with administrative support, could be dialogue with the nurse practitioners and physicians in the emergency department. Dialogue may allow better processes for information sharing, protocol development for likely presenting signs and symptoms among patients with cancer visiting the emergency department, and discussions about the best method of integrating palliative care.

Bakitas, M., Stevens, M., Ahles, T., Kirn, M., Skalla, K., Kane, N., & Greenberg, E.R. (2004). Project ENABLE: A palliative care demonstration project for advanced cancer patients in three settings. Journal of Palliative Medicine, 7(2), 363–372.

Barbera, L., Taylor, C., & Dudgeon, D. (2010). Why do patients with cancer visit the emergency department near the end of life? Canadian Medical Association Journal, 182(6), 563–568.

Mayer, D.K., Travers, D., Wyss, A., Leak, A., & Waller, A. (2011). Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. Journal of Clinical Oncology, 29(19), 2683–2688.

Quest, T.E., Asplin, B.R., Cairns, C.B., Hwang, U., & Pines, J.M. (2011). Research priorities for palliative and end-of-life care in the emergency setting. Academic Emergency Medicine, 18(6), e70–e76.

Rosenberg, M., & Rosenberg, L. (2013). Integrated model of palliative care in the emergency department. Western Journal of Emergency Medicine, 14(6), 633.

Slavish, K. (2013). Utilization of acute services among women with metastatic breast cancer at the end of life. (Unpublished master’s thesis). University of Pittsburgh, Pittsburgh, PA.

Temel, J.S., Greer, J.A., Muzikansky, A., Gallagher, E.R., Admane, S., Jackson, V.A., . . . Lynch, T.J. (2010). Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine, 363(8), 733–742.

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

Exclusive Articles Available Before Print

The Oncology Nursing Forum (ONF) and the Clinical Journal of Oncology Nursing (CJON) have unveiled advanced print exclusive articles to give our readers access to important, cutting-edge content ahead of print. Articles from the journals are available on the main ONF and CJON pages. These articles are open access, meaning they are available to members and non-members alike, until they appear in print at a later date. At that time, the content will become password-protected like other articles that appear in print as online exclusives in the journals.

The latest article to receive the advanced print exclusive designation is “Cognitive Behavioral Therapy for Insomnia Outcomes in Women After Primary Breast Cancer Treatment: A Randomized, Controlled Trial” by Ellyn E. Matthews, PhD, RN, AOCNS®, CBSM; Ann M. Berger, PhD, APRN, AOCNS®, FAAN; Sarah J. Schmiege, PhD; Paul F. Cook, PhD; Michaela S. McCarthy, RN, MS; Camille M. Moore, MS; and Mark S. Aloia, PhD, CBSM. The purpose of this ONF article is to examine the effect of cognitive-behavioral therapy for insomnia on sleep improvement, daytime symptoms, and quality of life in breast cancer survivors after cancer treatment. Check out this timely and informative article today.

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

Check out the ONS Connect Blog

The official blog of ONS is written by oncology nurses for oncology nurses on a variety of topics of interest, including facing day-to-day challenges at work, juggling busy lives at home, and keeping up to date with the magnitude of information available for practicing nurses.

This month, you’ll find the following new discussions.

As a reader, join in on the conversation and connect with other oncology nurse readers by posting your own stories, tips, ideas, and suggestions in the comments section at the end of each blog post.

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

Five-Minute In-Service

The latest Five-Minute In-Service explains how the U.S. Survey Reports Oral Chemotherapy Practice and Safety Patterns.

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

Ask a Team Member

The latest Ask a Team Member column answers the question What Should Nurses Know About Statistics to Better Understand Reported Oncology Research Results?

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

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Nurse Practitioner

Special Interest Group Newsletter  April 2014

Nurse Practitioner SIG Officers

Coordinator (2012-2014)
Tamika Turner, MS, NP-C, AOCNP®
Indianapolis, IN

Ex-Officio (2012-2013)
Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Sewickley, PA

Margaret (Peg) Rosenzweig, PhD, FNP-BC, AOCNP®
Sewickley, PA

Web Page Administrator
Barbara Biedrzycki, RN, MSN, CRNP, AOCNP®


Legislative Issues
Wendy H. Vogel, RN, MSN, FNP, AOCNP®
Bristol, TN

Barbara Biedrzycki, RN, MSN, CRNP, AOCNP®

ONS Copy Editor
Jessica Moore, BA, BS
Pittsburgh, PA

Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Specialist Carol DeMarco at or 866-257-4ONS, ext. 6230.

View past newsletters.

ONS Membership & Component Relations Department Contact Information

Brian K. Theil, CAE, Director of Membership and Component Relations Department

Diane Scheuring, MBA, CAE, CMP, Manager of Member Services

Carol DeMarco, Membership Specialist—SIGs

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

Oncology Nursing Society
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