Palliative Care Nurse Coordinator

Integrates and coordinates the palliative care of individuals across the healthcare continuum. Participates in the development of an interdisciplinary plan of care to meet the needs of the palliative care patient and family. Serves to coordinate an integrated support system for the palliative care patient and family to ensure successful transitions from various levels of care or at crucial points in the patient's disease process.

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• For the inpatient service, works collaboratively with the palliative care providers to triage referrals to the Palliative Care Service, to determine appropriate level of intervention and urgency of intervention.
• Performs focused palliative care evaluation of patients which may include the initial assessment.
• Works in collaboration with the palliative care provider and the other interdisciplinary team members to establish a plan of care for the patient that includes symptom management.
• Provides education to the palliative care patient and their family regarding chronic disease management and symptoms and advance care planning.
• Together with the patient and family establishes the patient's goals of care and communicates those goals in written documentation in the medical record as well as verbally to other care providers as needed.
• Together with other interdisciplinary team members, organizes and conducts the patient and family meeting for the purpose of facilitating clear and ongoing communication regarding the patient's plan of care.
• Demonstrates a working knowledge of chronic disease management and treatment.
• Re-assesses the patient's goals of care and the plan of care on a regular basis, especially during crucial turning points of disease progression.
• Serves as a resource to other care givers regarding palliative care and end of life care management of patients.
• Demonstrates a working knowledge of the various levels of care including acute care, skilled care, long-term care, and hospice.