This Month, Everything Changed for PAs

After days of debate and years of dreaming, collaboration and study, an entire profession has embraced their future.

by Beth Smolko, MMS, PA-C

After days of debate and years of dreaming, collaboration and study, the resolution called “Optimal Team Practice” (OTP) came up for a vote in the American Academy of PAs (AAPA) House of Delegates (HOD). I remember hearing the Speaker call for all votes in favor and although there was a good response, I couldn’t tell if it was a majority. Then, the Speaker called for “all opposed” and there was silence. Pure, beautiful, silence. It was in that moment that an entire profession embraced their future.

In years past, a determined and legendary PA leader, David Mittman, started saying we needed Full Practice Authority/Responsibility in order for the PA profession to survive and thrive. Many PAs did not want to risk future PA legislation by angering physicians with FPA. We saw the fierce battles the NPs had to engage in and realized that we would have to fight the state Board of Medicine in almost every state without the same level of protection that comes from having your own state board (like nursing). As the years went on, we saw our nurse colleagues fight battle after battle, state after state, and even though the physician groups bemoaned their success, they didn’t cease to hire NPs. In the past year, it became clear that physician groups were actually preferentially hiring NPs due to the reduced administrative burden, over “dependent” practitioners like PAs. PAs who felt that physicians would continue to hire them due to PAs practicing in the same “medical model” or staying “in our place” were sadly mistaken. As physicians had increasingly become employees instead of solo practitioners, they no longer wanted the professional liability that comes from having to “supervise” another professional.

Almost two years ago, I led an advocacy team for primary care PAs (AFPPA) joining with the PAs for Tomorrow (PAFT) and Brian Sady (a passionate educator from Nevada who wrote a comprehensive white paper on FPA for PAs) to address PA practice authority. We worked diligently to create a resolution to bring to the 2016 AAPA HOD to introduce Full Practice Responsibility (FPR). There was vigorous debate on the house floor but ultimately the resolution was referred for further study. From this point, the HOD and AAPA Board of Directors (BOD) formed the Joint Task Force on the Future of PA Practice Authority (JTF). The JTF reflected the diversity found in our profession. It was made up of clinically practicing PAs, educators, state PA leaders, and two PAs who work for the Veterans Administration. It was a group that would have to come to consensus on ideas and language that would be best for our patients, our profession, and our stakeholders.

Over the past 10 months, the JTF worked with AAPA staff to create the most transparent and member-engagement driven process in our organization’s history. They sought to understand the wishes, needs, and will of their constituents. The concept was named Full Practice Authority and Responsibility (FPAR) and consisted of four “pillars”:

  1. Emphasize the PA profession’s continued commitment to team-based practice.
  2. Support the elimination of provisions in laws and regulations that require a PA to have and/or report a supervisory, collaborating, or other specific relationship with a physician in order to practice.
  3. Advocate for the establishment of autonomous state boards, with a voting membership comprised of a majority of PAs, to license, regulate, and discipline PAs.
  4. Ensure that PAs are eligible to be reimbursed directly by public and private insurance.

A survey was released on FPAR with over 12,000 PAs responding and over 71% in favor of the concept. The AAPA held calls with state chapters, specialty organizations, students, program directors, PA Administrators, past presidents and a variety of other PA leaders, as well as external stakeholders to field questions and explain the concept of FPAR. The AAPA also received thousands of emails, comments on social media, and letters regarding FPAR. PA leaders met with multiple physician organizations to discuss the proposal under consideration. By March, it appeared clear that this would be the way forward, but slow deliberation is the hallmark of PA leadership. During the Leadership and Advocacy Summit held in March 2017, we heard concerns from some attendees, including PA educators, which led to rethinking the name and some of the language originally proposed by the task force. As the pillars would directly impact AAPA’s Model State Legislation, they were added to the guidelines document as opposed to creating a “stand alone” resolution. The pillars were given a new name — “Optimal Team Practice” (OTP). This change in language gave some assurance to PAs that felt teamwork was important to emphasize. They wanted it to be clear that PAs weren’t going “rogue”, but rather wanted to be better teammates by not burdening any other teammate with “supervision”.

So, once again, I found myself on the floor of the HOD last week, asking for my colleagues to consider the future of our profession and the impact OTP would have on patient access to care. And after two days of debate, it ended in silence… followed by cheers, tears, and emotion unlike anything I’ve ever seen from our profession. It was a moment that changed everything – how PAs see themselves as a profession, where we belong in the healthcare landscape, and how we can expand access to care for our patients.


Beth Smolko is a certified PA with experience in primary care and occupational health and wellness. While in PA school, Beth volunteered in a mobile medical unit in Tucson, AZ which ignited her passion for bringing quality medical care to the underserved outside the walls of a clinic. Beth is a recognized leader in primary care with professional roles that include: Director-at-Large, American Academy of PAs (AAPA); Past President of the Association of Family Practice Physician Assistants (AFPPA); PA Representative at the 2013 and 2014 World Hepatitis Day meetings held at the White House; HCV Testing Recommendations Implementation Panel – Healthcare Providers (Centers for Disease Control). Participant representing PAs in the discussion on the Implementation of Hepatitis C Screening Recommendations for Patients born between 1945-65; Preceptor for George Washington University, Franklin Pierce and Salus University PA Programs. Preceptor for LECOM. Preceptor for University of Michigan Nurse Practitioner program; Guest lecturer for Mary Baldwin – Murphy Deming and George Washington University PA program speaking on “Pulmonary Disease” and “Family Medicine”; President and Founder of The Heart of Medicine, a non-profit connecting healthcare providers with patients desperately in need of care in Haiti.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

PAs Vote to Advance Profession to Meet Modern Healthcare Needs

PAs pass policy to enhance their ability to meet patient needs and ensure future of the profession.

from AAPA

At the annual conference of the American Academy of PAs (AAPA), members of its House of Delegates unanimously approved Optimal Team Practice, a new policy intended to enhance the ability of PAs to meet the needs of patients and ensure the future of the profession in a changing healthcare marketplace. This historic action comes during the 50th anniversary of the PA Profession, which was initially created to improve and expand healthcare.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: What Patients Want: Recognize My Individuality Despite My Chronic Illness(es) and Value Me as a Patient

We need to look at people individually. Get to know the person behind the office or hospital visit. Ask the questions to help provide the best care.

by Kimberly Spering, MSN, FNP-BC

All is not as it may seem… on first appearances.

I met J., a gentleman not one decade older than I am, on the first real “spring” day in May. I’d reviewed his extensive chart and multiple hospitalizations before I did the visit. What I read was disheartening, sad, and oh-so-hopeless at first.

He was diagnosed over 20 years ago with a disorder causing idiopathic arterial clotting. In the subsequent two-plus decades, he had multiple amputations… starting from the toes, to feet, to lower and upper limbs. At the time of my visit, he was a triple-amputee with one thumb and forefinger remaining. Of note, he could not USE those digits, being “frozen” of sorts. He has chronic, unrelenting pain. A horrific, stage 4 sacral and gluteal ulcer that has been surgically debrided multiple times. A colostomy and suprapubic catheter to divert stool and urine away from the ulceration. Anxiety and depression (and who wouldn’t have this, given everything?).

Incidentally, he had signed out AMA on multiple occasions after surgical debridement of the sacral/gluteal wound. What was worse, he was labeled “non-compliant on many occasions.” He tried to leave AMA on this last admission (mind you, without legs) and fell to the floor from his hospital bed.

I sensed the frustration in the hospital notes from multiple providers. The feeling I got, reading these notes, was “Oh well, he left AMA.”

The first thing his wife said upon my introductions was, “I bet you want to ask about why he left AMA.”

“Actually, no — that wasn’t going to be a topic initially. Would you like to talk about it?” I asked.

It turns out, he felt most comfortable being cared for by his wife and daughters…not strangers whom he felt “judged him,” looked at him as though he was a circus side-show act, and doctors who he felt didn’t make an effort to understand his rationale for leaving AMA. I’d daresay, if I had suffered the indignities he had, I’d have left AMA as well.

“The fact is, after he has his surgical debridement, he just wants to go home. That’s it. He’s not trying to be difficult,” his wife told me.

Unfortunately, he has needed multiple debridements of this wound. Upon my exam today, it was obvious it needed surgical debridement again. Despite a wound-vac placement, the amount of drainage and odor was unbelievable. I can say this was the worst wound that I’ve personally witnessed in 26+ years of nursing.

We discussed the barriers to his getting care, to his leaving AMA, his protein deficiency, dietary limitations, and likeliness that this wound would never heal. His wife started crying, then thanked me. “I’ve asked the doctors to be straight with me about this wound. I’ve been told, ‘it will heal.’ All I want is the truth.”

Couple this with the fact that he has chronic pain with a myriad of sources: embolization, DVT, neuropathy, ulcerations, etc. He uses marijuana 1 – 2 times per day to help with his pain and anxiety. He has multiple allergies to narcotics. His daughter, seeing him writhing in pain one day, told him, “I can’t stand to see you like this,” and gave him one of her Percocet. This helped his pain. Ironically, when he and his wife told this to providers, he was immediately labeled as a “drug addict” and abuser. As a result, no one was comfortable prescribing narcotics.

I found myself getting angry about how this had panned out. I’m not one to judge another provider, and honestly, I know if I had only seen the “AMA” sign-out multiple times, hearing about using a narcotic from someone else, without hearing the “whole” story, I’d be jaded as well.

Let’s think about this situation for a moment. A virtual quadriplegic patient that has no use of any limbs. Chronic pain. Severe muscle spasms and restless leg syndrome. Severe depression and anxiety. No end of this pain in sight, and likely to endure multiple more debridements, more amputations, and a lower quality of life than any of us could imagine.

Is it any wonder why the patient and his wife were frustrated? And yes, I GET that I, in my palliative, home-based NP role, I have the luxury of time to spend, to figure out the nuances of the individual situation, and to SEE the WHOLE person.

One cannot easily determine these issues during an office visit or hospital stay, without spending a lot of time getting the information. I GET it.

However, his case proves again (to me at least) that we need to look at people individually. Get to know the PERSON behind the office or hospital visit. ASK the questions to help provide the best care.

Anyone with chronic pain will tell you…there are days where you will do ANYTHING to get relief – legal or not. I don’t really care if he’s using marijuana to help his symptoms. I don’t care if his daughter, out of desperation, gave him one Percocet. I AM willing to work with him to develop a comprehensive plan for managing his pain, depression, and anxiety. I counseled him on the need for ONE provider to prescribe pain medication. No diversion, lost prescriptions, or “excuses.”

His wife cried. “I am so grateful that you believe us.”

I changed his antidepressant to one to affect his depression, anxiety, and neuropathy. I prescribed his Dilaudid under strict parameters. I corresponded with his PCP and surgeon about his worsening wound and need for debridement. I also counseled the patient that, when he was admitted again, it would be a good idea to try to stay for the duration of treatment, rather than sign out AMA. Not everyone (if anyone) will read my notes about his reasons for signing himself out. He deserves comprehensive, NON-JUDGEMENTAL care from all arenas.

I daresay none of us can imagine the living HELL that he experiences on a daily basis. We don’t want to personally experience his intimate details of his pain, depression, anxiety, or perceived bias from other health care providers.

Perhaps, we should just remember the following:

I have a chronic illness.

It’s not contagious.

I’m not lazy.

I’m not faking.

I hate to cancel plans.

I’m not a hypochondriac.

I’m not crazy.

I’m not weak.

I want to work.

I don’t enjoy this.

I’m not an addict.

I’m not looking for attention.

I have a chronic illness.

Don’t judge.

Show support.


Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Research on the PA Profession: The Medical Model Shifts

In an era where demand for medical services is outstripping supply, a good idea born in the 1960s is emerging as a medical innovation domestically and globally.

from JAAPA

Physician assistant (PA)-focused research arose in response to the idea that an assistant to the busy physician could improve healthcare delivery. The process of answering questions about the profession has involved multiple approaches and various scholarly disciplines. In the course of this undertaking, what emerged were three stages of examination of PA behavior. The bibliographic span from this period contains about 2,400 studies that advance some notion of PA benefit to society. On the 50th anniversary of the PA profession, a question arises as to what research has shown. The answer is that PAs are providing care at significant levels of quality and quantity and their presence is enriching many challenges in healthcare delivery. In an era where demand for medical services is outstripping supply, the good idea born in the 1960s is emerging as a medical innovation domestically and globally.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Do NP, PA Ordering Habits Lead to Higher Healthcare Costs?

A study found that primary care provider ordering habits may result in higher healthcare costs versus the habits of nurse practitioners and physician assistants.

from RevCycleIntelligence

Nurse practitioners and physician assistants did not contribute to higher healthcare costs by ordering more ancillary or expensive services compared to primary care providers, a recent American Journal of Managed Care study uncovered.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: Circling Around Difficulties in Obtaining Patient Care

Advocating for patients’ needs is crucial. Are you up to the task?

by Kimberly Spering, MSN, FNP-BC

It was a late winter day when I met “J,” a patient who had already endured so much in her lifetime, and one who made me shudder with the thought of someday meeting the same fate.

“J” had suffered a CVA in 2002, resulting in dysphagia, aspiration, and the placement of a PEG tube for nutritional support. Over the years, she went from being ambulatory to bed-bound for the past three years. “She just stopped walking one day,” I was told. She had expressive aphasia, severe extremity contractures from immobility, and the worst unstageable skin ulcer I’d seen in 26 years of practice.

The unbelievable stench of that wound met me as I walked half-way up the steps of the row home. Let me say, there is very little that makes me nauseous. After all, working in critical care, trauma, and in patients’ homes with less-than-stellar cleanliness, it takes an awful lot to make my stomach turn. I’ve discussed autopsy results and trauma incidents during dinner without batting an eyelash. But my stomach twisted and churned on that day.

I sat on the floor of the tiny, 8-foot square bedroom, because there was no room for a chair, and I was afraid to sit on the bed, which had seen better days and probably had a plethora of bacteria and secretions. Unfortunately, that also meant that I sat by the waste basket which held the soiled wipes and dressings from the wound care change. No matter. I set out to do what we palliative home-based NPs do.

Her left hip wound was unstageable, bleeding, and draining purulent drainage. She would only lie on her left side; the aide and family noted that she grimaced and appeared to silently scream while lying on her right side, so they kept her on the left side, no matter what. We discussed her poor nutritional status, the unlikeliness for the wound to ever heal, and the possibility of signing on to hospice care, which she definitely qualified for. Her daughter wanted to discuss the issues with her siblings. On the follow-up visits, they wished for the patient to remain home and not pursue hospice at that point.

Over the course of three visits, her situation and wound worsened. I had asked for her PCP to order home-based wound care nurse visits to try to help the wound bed as much as possible. Despite multiple phone calls and messages through the EMR, every time I returned, no wound care was ordered.

One day, I opened up my EMR to find a message from nurse who worked with the PCP. “J” has not had a visit in two years; we will not write orders for wound care.”

Um, never mind that the patient was bed-bound and getting her out of bed to a wheelchair was impossible. Never mind that I offered to document the face-to-face visit to demonstrate the need for care. My repeated pleas fell on deaf ears.

I messaged a wound care NP and asked for a “curb-side consult” about treatment, after describing her wound in detail. She was gracious enough to lend her expertise and advice, and the medication was ordered. However, I wanted someone in the home to evaluate the patient and follow-up on her care.

So, as we do when faced with obstacles, I had my staff order the nursing wound care consultation under my collaborating physician. I don’t like to do that, but frankly, I’ll do what needs to be done for the patient’s benefit. Since Medicare does not allow us home-based NPs to order wound care, we sometimes work around the system in a legal fashion.

Fast forward a few weeks. I received a phone call from the clinical manager of the home care agency. “My nurses went out and are appalled at the home situation and gravity of “J’s” wound. Do you think it would be appropriate to admit her to the hospital for evaluation & treatment, then pursue hospice?”

I agreed with this request. She and the nurse made a home visit to the patient & daughter, explaining their concerns about the need for more advanced care and hospice services. The patient was admitted. I facilitated an inpatient palliative consultation with the patient and family. Ultimately, hospice services were initiated, and the patient was transferred home to receive this extra layer of supportive care.

What frustrates me to no end is the lack of continuity of care in this case. The PCP was the one to order our home-based palliative care consultation. My information and notes were shared with him monthly. I sent separate messages and made phone calls to the PCP…without getting any orders.

The biggest hold-up, from what I can tell, was from the clinical staff nurse who looked at her appointment history and decided, on her own, that no orders were to be given. I reviewed all of those notes: the physician was NEVER informed of my phone calls requesting orders; or at least, there was no mention of his notification in the chart. To make matters worse, IMHO, the person making this decision to not provide a consultation was a NURSE. Not an MA or other assistant. But someone who should have clinical decision-making to look at an individual case and decide to take it further with the provider. What was equally as disturbing is that all of my personal emails to her PCP went unheeded.

Yes, there are “rules” about giving orders, refills, etc., for patients who have not been seen recently.

However, c’mon! A bed-bound, frail, 70-pound lady who can’t get into a wheelchair? Can you, say, be an advocate for personalized care?

I’m frustrated at the nurse’s lack of understanding…compassion…whatever you want to call it. I’m frustrated by the “system” who reportedly makes these “rules” about not ordering things if the patient hasn’t been seen. Yes, I get the liability factor. I’m frustrated at the multiple attempts at communication to this PCP – unheeded.

When, if ever, will the health care “system” look at patients individually? I do, every day. I have to. My position necessitates it, because patients will fall “out of the box” frequently. I suspect most of us try to do that. But the “system” obstacles can seem insurmountable.

Ultimately, the patient had to be admitted to secure hospice services and the extra layer of support. How much did that cost?

Look at your own practice. Do you see issues that you can intervene to make a difference? It may not be a severe wound in a bed-bound patient. It may be a barrier that patients face – getting appointments to specialists, ordering DME equipment, coordinating care, ordering necessary medications, etc.

We cannot afford to just follow the “status-quo.” These are patients with multiple, often seemingly-insurmountable problems. Lend your voice to those who need one. Support your patients to get the care that they need and deserve.

If our efforts help even one patient, stuck in the quagmire of medicine “rules,” our patients and our own conscience will thank you for your efforts.


Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Outside the Clinic

There are many options for PAs beyond clinical work.

from AAPA

Do you ever wonder about the options for nonclinical employment open to you as a PA? There are many available. AAPA has highlighted 10+ possibilities, as well as some questions to ask yourself to see if non-clinical work is a good fit for you.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Nurse Licensing Laws Block Treatment for Opioid Addiction

Laws in more than half the states are likely to prevent NPs from using their licenses in rural areas that need it most.

from The Pew Charitable Trusts

Confronting an opioid overdose epidemic that is killing at least 90 people every day, two federal agencies this month gave more than 700 nurse practitioners and physician assistants the authority to write prescriptions for the anti-addiction medication buprenorphine.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Equipping PAs for Expanded Opportunities in Healthcare

Nearly three-quarters of PAs now say that their main area of practice is in a specialty other than primary care.

from AAPA

Many factors, including consumer empowerment and a heightened focus on healthcare quality and patient safety, are increasing the scrutiny of how providers develop and demonstrate clinical competency. The PA profession has been changing as well, with the percentage of PAs practicing in non–primary care specialties rising steadily over the past two decades.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: Asking Crucial Conversation Questions

Discussing end-of-life wishes is exceptionally difficult, for us as providers, as well as patients. However, if we can give a last bit of dignity to that person in the end of life, we’ve done an extraordinary thing.

by Kimberly Spering, MSN, FNP-BC

I met this patient on an early spring day. The snowstorm of the past month was but a distant memory. It took me a few passes by the driveway to realize that, yes, this was the home of my patient. I drove up to the house, spaced back from the main road, with parking signs noted about 50 feet from the abode.

Gathering my computer bag and backpack with my medical supplies, I walked up the graceful arch of the front walk. Ringing the doorbell, I braced myself for the inevitable nuances of a first visit in my palliative NP role.

After my introduction, the patient’s spouse graciously welcomed me into their home of 60 years. A medical professional in his past life, my role was understood and welcomed. That doesn’t always happen in my work… but I appreciated the ease with which I was accepted into their home.

After a dissecting thoracic aneurysm and subsequent severe CVA, the patient had spent months in a skilled nursing facility. Quite honestly, the patient had the proverbial “nine lives” of a cat, given her medical set-backs. The spouse journeyed to the nursing home three times daily to feed her. Why? “No one else will take the time.” After many long months of care, the insurance was running out. “It would cost me over $500 daily to keep her there. I want to care for her at home.” So, she was discharged from the skilled nursing facility to the home that she stayed in since her marriage.

I met this lovely woman, a shell of her previous existence, but yet…she maintained the spark of her intelligence, even if her body could not respond in kind. She had visual deficits and could only track from one side. I positioned myself on her good side to talk with her. Her words were few, her gestures limited… but still, I could sense the proud, dignified woman that she had been prior to her illness.

“I want to help you… to manage your symptoms, and to help you achieve your goals of care. Tell me what is most important to you at this time.”

Her words were limited. Her husband filled in the details. I sensed his exhaustion from the past many months of care… trying, unsuccessfully, to have her return to her former level of functioning. He was not initially willing to acknowledge her level of disability. Slowly, I discussed her overall status.

“I’m concerned that she is having symptoms that are not controlled. I am worried that her health situation is grave, and that if something unexpected happens, that she will not survive. Has she discussed her end-of-life wishes if her health deteriorates?”

Slowly, in a trance, he looked up at me. The emotion of relief washed across his face. “No one has talked about this… until now,” he said. “I’m worried about what will happen if she declines. I know that she will not survive.”

Gently, I discussed her end-of-life wishes. Reiterated that a “no code” status does not mean “no care.” I know that I personally would not want to live in that boxed-up state for any amount of time. He was frank, almost outspoken in his words about her wishes. I documented these issues for future use.

However, at this point, he wanted everything possible to be done at this point, including full code status. We discussed the ramifications of what running a code would entail for her. No matter — this was his wish. She agreed with him. And we will honor her wishes. However, honestly, the chance of survival in a code scenario is slim-to-none. All I could do is document this discussion and the response.

So what is a “life worth living?” Is it someone who is but a shadow of her prior experience? Is it someone with full capacity, but physical limitations? Or… is it someone who says “life is worth living in this moment,” no matter what that moment may be. It may not be your or my moment… nor our own decision, but rather, someone who chooses LIFE, no matter what the experience, what the cost. A life worth living is determined by EACH individual, in EACH situation. We may have a different perspective on that issue, but our own experiences affect our reactions. We owe it to our patients to ask those tough questions.

I encourage you to discuss these issues with your patients, particularly if they have an end-of-life illness. So often, I hear, “I don’t have time to discuss these issues.” I get it, having worked in an office setting most of my NP career. However, Medicare now reimburses you for these discussions, which, quite frankly, may be the most important ones you have with your patients.

Discussing end-of-life wishes is exceptionally difficult. Most of us don’t like to imagine that scenario. It’s uncomfortable for us as providers, as well as patients. However, if we can document a patient’s wishes, and give a last bit of dignity to that person in the end of life, particularly if he/she is unable to verbalize those wishes — we’ve done an extraordinary thing.

I challenge you to look at your chronically ill patients. Think about opening the conversation with these questions regarding serious illness:

  1. What is your understanding of where you are with your illness?
  2. How much information about what is likely to be ahead would you like from me?
  3. If your health situation worsens, what are your most important goals?
  4. What are your biggest fears and worries about the future with your health?
  5. What abilities are so critical to your life, that you can’t imagine living without them?
  6. If you become sicker, how much are you willing to go through for the possibility of gaining more time?
  7. How much does your family know about your wishes?

These serious conversation questions are crucial to open conversations and begin dialog with patients. Try asking these questions. It gets easier, the more often you do it. And…your patients and families will thank you.


Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.