On the other end of the age continuum, the Palliative Care Center of the Bluegrass, in Lexington, Kentucky, employs nurse practitioners who serve as external palliative care consultants to nursing home staff, residents, and their families. These consults can be initiated by physicians or nursing directors at the nursing homes. The nurse practitioners provide both clinical consultation and education to nursing home staff, focusing on symptom management, advance care planning, patient and family communication, and supporting transitions to hospice services, if needed. Both Medicare and Medicaid will provide reimbursement for this type of external consultation provided by a nurse practitioner. Nursing homes who have used this consultation service report improved pain and symptom management, increased patient satisfaction, and fewer emergency room transfers. This Center has been nationally recognized as one of the Palliative Care Leadership Centers by the Center to Advance Palliative Care (CAPC, 2008).

Advanced practice nurses in critical care units, such as Margaret Campbell, PhD, RN at Detroit Receiving Hospital in Michigan and Patrick Coyne, MSN, APRN, at Virginia Commonwealth University, have also demonstrated the effectiveness of interventions by palliative care services within their institutions. Campbell has developed protocols that promote both physical and emotional comfort to patients and families during the process of weaning patients from mechanical ventilation (Campbell, 1998). Coyne and colleagues have demonstrated significant improvements in their patients with pain, nausea, depression, anxiety, and shortness of breath (Coyne, 2009; Khatcheressian et al., 2005).

Palliative care interventions enhance physical and psychological well-being, enhance communication between patients, families, and caregivers, increase patient and family satisfaction, and facilitate transitions through complex care delivery environments. Beyond these benefits, palliative care tends to be a costeffective model of care delivery. A recent multisite study by Morrison and colleagues (2008) demonstrated significant reductions in pharmacy, laboratory, and intensive care unit costs. In their study, which included over 5,000 hospitalized palliative care patients, the palliative care patients who died had a net savings of $4908 per hospital admission, and palliative care patients who were discharged alive had a net savings of $1696 per admission, in comparison to matched cohorts of comparable patients who received usual care.

Palliative care is a model that is consistent with basic nursing values, which include caring for patients and their families regardless of their age, culture,