Trust, compassion and end-of-life care in the Rio Grande Valley
From a young age, Merlyn Palacios, APRN, knew she wanted to pursue a career in health care. As a child, she spent time hanging around the doctor’s office where her mother worked for nearly 20 years. Palacios watched, fascinated, as the doctor performed everything from injections to sutures. But her favorite thing to do while at the clinic was explore the medication room. Palacios knew the room inside and out, and went from medication to medication, reading their labels to find out what they do and how they work.
APRN Palacios formally explored her curiosity for medicine while attending the University of Texas–Pan American (now University of Texas Rio Grande Valley) in Edinburg, Texas. After spending so much time listening, learning and reading about medications, she instinctively pursued a degree in pharmacology.
However, something didn’t feel quite right. While she enjoyed learning about the finer points of medications something was missing. After spending some time running it through her head and going through her undergraduate classes, she finally figured it out.
“When I first went to school I wanted to be a pharmacist,” said APRN Palacios, “but while I was an undergrad student I started to realize I wanted more patient interaction.”
Once she came to this realization, she quickly changed her major to nursing and dove straight in. She graduated with a bachelor’s degree in nursing and went on to complete her master’s degree at UT Pan American as well.
APRN Palacios’s first rotations as a nursing student were focused on labor and delivery; however, she always enjoyed working with the elderly population. Little did she know that her career would lead her to palliative care. Unlike hospice care, palliative care allows patients to continue to seek aggressive curative treatments for chronic conditions while planning for end-of-life.
She joined the WellMed Palliative Care team in the Rio Grande Valley (RGV) in 2015 without any idea of what to expect. It was a completely new experience for her and the patients in the Rio Grande Valley as well. Although she was eager to help her new patient base, APRN Palacios encountered a resistance against the program that put her at a disadvantage, at least initially.
“The Hispanic culture in RGV is very resistant to ideas like hospice care,” she explained. “They believe even talking about death is like inviting death to their door. Having that conversation with older patients here gets a lot of pushback. I needed to learn to adjust my conversations to better help them.”
APRN Palacios tackled the challenge headfirst. After implementing a new “teach first, talk about advance care planning last” approach, patient outcomes for the palliative care program in the RGV improved. By using a team approach and working closely together, the palliative care team in the RGV has seen a decline in the number of ER and hospital admission and readmission rates, and costs for care have declined for high risk palliative care patients.
APRN Palacios also decided to take a step further. As a Doctor of Nursing Practice (DNP) student at the University of Texas Health Science Center in Houston, APRN Palacios had to work on a quality improvement project. She decided to work with community health workers, known locally as “promotoras,” who are highly respected in the RGV and trusted in the Hispanic community. The goal of the pilot study was to utilize promotoras to engage elderly Hispanic people in advance care planning and to increase the completion of advance directives.
She collaborated with another DNP graduate and a social worker to help build a curriculum about how to do advance care planning. They also partnered with the Lower Rio Grande Valley Area Health Education Center, which works closely with promotoras and is affiliated with the University of Texas Health Science Center at San Antonio, and they were able to use the curriculum to provide training and education for a promotora. The promotora also shadowed Palacios, and once the promotora was ready to go on her own, she was able to see patients in their homes. APRN Palacios did advance care planning at every initial evaluation, but there were some patients who were not ready to complete an advance directive after their initial visit. They began using the promotora to gently educate the patients and form a relationship that would allow patients to open up about their end-of-life wishes.
The patients were very receptive to the promotora, and APRN Palacios noticed the change almost immediately – the patients were more forthcoming with the community health worker because they talked about their health issues first. The patients were also willing to complete either a medical power of attorney or an out of hospital do not resuscitate after receiving education from the promotora. The promotora was successful in completing an advance directive after having conversations with patients. The promotora was able to visit several patients in their homes and was able to increase advance directive completion to nearly 90%.
The experience taught APRN Palacios an important lesson about her patient base and the importance of using community health workers to help engage the Hispanic community in advance care planning. Therefore, APRN Palacios along with the DNP and social worker, have submitted the curriculum used in the pilot study to the State of Texas and are pending approval. Once the curriculum has been approved, they will be teaching about 25 community health workers about advance care planning so that the community health workers can go out and teach the Hispanic community about its importance.
“The more I’ve worked in palliative care, the more I realized patients need someone who is compassionate to care for them at the end of their lives. We try to be compassionate and sensitive to our patients’ wishes. We think of how we can respect their wishes while making sure they maintain a decent quality of life regardless of how long they have to live,” said APRN Palacios.
Compassion and education provided APRN Palacios and the palliative care team the means to improve outcomes and relationships with their patients. Now, she continues to pursue her passion and dedication to medicine that first started when she was just a small girl rummaging around the medication room and reading every label in sight. She hopes to graduate with her degree as a DNP from the University of Texas Health Science Center in Houston, Texas in 2018