Date of Award

Fall 2023

Project Type

Clinical Doctorate

College or School




Program or Major

Doctor of Nursing Practice

Degree Name


First Advisor

Gene Harkless

Second Advisor

Sara Robinson


BACKGROUND: The United States health care system faces the dual challenge of an aging population with a concomitant increase in the presence of chronic and serious illness, the care of which accounts for the nation’s largest expenditure of burgeoning healthcare costs. Palliative care is specialized care for people with serious illness aimed at reducing suffering, optimizing quality of life, and enhancing medical decision making. An ample evidence base demonstrates that palliative care increases both quality of care and patient and family satisfaction while also reducing associated costs. The aim of this quality improvement project was to facilitate palliative care services to patients and families through the identification of potential unmet palliative care needs using educational and screening interventions.

METHODS: The DMAIC QI framework approach of Lean Six Sigma was utilized to structure this quality improvement project. An initial needs assessment was performed utilizing targeted ICD-10 codes to extract three-month and twelve-month emergency department data from three critical access hospitals (CAHs) to provide a broad overview of potential unmet palliative care needs. One CAH was then selected to serve as the pilot site for the subsequent 30-day inpatient and emergency department patient screenings utilizing the Palliative Care Screening Tool (PCST) and educational intervention assigned to identified nurses at the facility. The Palliative Care Self-Efficacy Scale (PCSES) was employed to measure knowledge and confidence with associated palliative care concepts.

RESULTS: The PCST was completed on 77% of eligible inpatient admissions and 100% of emergency department encounters. Inpatient screening totals indicated the following: 12% of screened patients recommended for automatic palliative care referral, palliative care clinician review recommended for 21% of screened patients, and consideration of palliative care consultation for 29% of screened patients. Emergency department results in each category were lower (4%, 8% and 12 %, respectively). The educational intervention was completed by 72% of identified nurses. Results demonstrated an aggregate improvement in knowledge and confidence level across all twelve domains in the PCSE.

CONCLUSIONS: Early identification of potential unmet palliative care needs provides a health system the opportunity to increase quality of care and patient and family satisfaction while reducing costs. Utilization of a valid and reliable palliative care screening instrument along with generalist palliative care education provides mechanisms for clinicians to identify and advocate for palliative care for patients and families with serious illness. Missed opportunities for palliative care screening can be addressed through integration of a screening instrument in the health system electronic health record (EHR).