Bridging the Gap: A Hospitalist-Designed, Nurse-Driven Palliative Care Model in a Community Hospital

Palliative care is both a medical specialty and an art. However, the number of clinicians trained in palliative care is insufficient to meet the increasing demand for goals-of-care and advance care planning discussions.  Many hospitals lack embedded palliative care teams, which means high-need patients may go without timely goals-of-care conversations, advance care planning, or hospice transitions. In an 86-bed community hospital that is part of a larger health system, there was no on-site palliative care service. Clinicians at the bedside were managing medically complex, high-acuity patients without structured support for these conversations. The result was delayed or inconsistent documentation of code status, unclear goals of care, and discharge plans that did not always align with patient values. The need was clear: create a scalable, sustainable model to deliver high-quality palliative communication without relying solely on scarce palliative-trained physicians and advanced practice practitioners (APPs).

Solution Overview

To address this gap, a 90-day pilot program was designed and implemented by a hospitalist and registered nurse care manager. The purpose was straightforward: expand access to early goals-of-care conversations, advance care planning, and appropriate hospice referral without waiting for a fully staffed specialty palliative team.

The pilot model reassigned core elements of palliative communication to a highly experienced nurse care manager. This nurse—trained through a formal End-of-Life Nursing Education Consortium course and mentored by inpatient palliative practitioners—served as the primary point of contact for patients and families.¹ The RN led bedside discussions about prognosis understanding, treatment preferences, resuscitation wishes, and post-acute options; documented advance directives; and facilitated alignment between the medical team and the patient’s stated goals.

Key objectives of the pilot were to:

• Identify eligible patients early in the admission^2,3
• Hold structured, compassionate goals-of-care discussions^4-9
• Normalize advance directive completion and code status review^10,11
• Support transitions to post-acute facilities or agencies, or hospice when appropriate

The stakeholders included hospitalists, bedside nurses, care management, speech therapy, and (when available) an APP from the division’s palliative team. The hospitalist champion and the RN care manager partnered to embed this workflow into multidisciplinary rounds, with daily follow-up as needed.

This model reframed palliative care from “a consult with a specialist” to “a core function of coordinated inpatient care,” making palliative principles available in a hospital that previously had none.

Implementation Process

Program design and training

Because no dedicated palliative service existed on campus, the hospitalist leader and a seasoned nurse care manager co-designed the pilot. The registered nurse (RN) selected for this role brought 27 years of clinical experience across maternal-child, trauma, inpatient case management, discharge planning, and utilization review, and held a national certificate in case management (CCM). She completed a two-day End-of-Life Nursing Education Consortium train-the-trainer course1 and spent two weeks shadowing experienced palliative care clinicians to build confidence and consistency in high-stakes conversations.

Early patient identification

The team implemented an early-trigger approach. Patients were screened within 72 hours of admission for serious chronic illness (advanced cancer, end-stage organ failure, end-stage renal disease, advanced dementia), frequent readmissions, loss of functional independence, and complex decision-making needs.^2,3 These triggers were reinforced in multidisciplinary rounds to surface candidates in real time rather than waiting for a traditional “palliative consult.” By design, this brought palliative thinking to the bedside on day 0 to 3, not day 8 to 10. In the pilot, 66.7% of consults occurred within 72 hours of admission.

Workflow at the bedside

Once the patient was identified, the RN met with them and/or the family, introduced the concept of palliative care as supportive, clarified understanding of the current medical situation, explored values and goals, and addressed preferences around interventions and resuscitation.^4-9,12 The RN encouraged completion of advance directives and documented code-status decisions.^10,11 Discussions regarding discharge planning options were held with patients and families to ensure alignment with goals and expectations. The RN also coordinated multidisciplinary family meetings with hospitalists, nursing leadership, care management, and ancillary services when needed for alignment and discharge planning. Follow-up visits were used to reinforce understanding, answer questions, and maintain trust.

Documentation and communication

A standardized documentation template in the electronic health record captured decision makers, goals of care, advance directives, healthcare surrogate designation, living will status, code status, psychosocial context, and discharge disposition planning. This ensured the entire care team saw the same plan, in the same language. This is critical in community settings, where handoffs are frequent, and verbal nuances can get lost.

Embedding in team culture

The palliative RN and palliative advanced practice registered nurse presented to physician groups both to clarify when to engage this process and to distinguish palliative care from hospice. Visibility on the units, participation in multi-disciplinary rounds, and informal curbside teaching increased awareness and normalcy. Speech therapy in particular became a reliable referral source after swallow evaluations flagged high-risk patients.

Barriers and how they were addressed:

• Barrier: Misconception that “palliative equals giving up.”
  Strategy: Reframed messaging around aligning care with patient goals at any stage of serious illness, not just end of life^4,7-9
• Barrier: Discomfort initiating high-stakes conversation
  Strategy: Provided scripting support, reinforced communication techniques (open-ended questions, silence, best-worst-most-likely-case framing), and modeled bedside language for physicians, nurses, and case managers.^4-6,9
• Barrier: Limited specialty staffing
  Strategy: Used the RN as the consistent, trained point person, with an APP from the system palliative care team available for medically or psychosocially complex cases.^1,7

The pilot ran for 90 days.

Outcomes and Impact

Over the 90-day pilot, 96 patients were seen by the nurse-led palliative workflow. Every patient received:

• A structured goals-of-care conversation
• A review of advance care planning and, when appropriate, completion of documents
• A discussion of code status and resuscitation preferences
• A discussion on discharge planning options
• Patient profile

The patients represented high-acuity, high-need populations: 24.8% had a cancer diagnosis; 26.3% had end-stage renal disease; 23.7% had dementia; 12.4% had congestive heart failure; and 12.4% had COPD.

Timing of intervention

Two-thirds (66.7%) of consults occurred within 72 hours of admission, which, in the literature, is associated with reduced length of stay and lower overall cost of care.^2,3 This timing matters: palliative alignment early in the admission helps drive appropriate disposition planning and avoids “crisis conversations” the night before discharge.

Advance care planning and code status clarity

Before the RN encountered them, only 36.5% of patients had a designated healthcare surrogate documented, and just 17.7% had a living will. After discussion, an additional 25% of patients completed a healthcare surrogate form, and an additional 17.7% completed a living will during the pilot.

Similarly, only 20.8% of patients had a documented do-not-resuscitate (DNR) order at the time of initial contact. After goals-of-care discussions, an additional 21.9% of patients chose and documented DNR status. This is a major patient-safety and ethical win: code status decisions were clarified proactively rather than in the middle of an emergency.

Discharge alignment

Most patients were discharged home, often with home health support; 30% were discharged either with home hospice or transferred to an inpatient hospice unit. Five-month chart review showed a mortality rate of 28.1% in the pilot population, underscoring that these were medically fragile patients for whom goal-concordant care is critical.

Cultural impact

Post-implementation surveys of physicians, nurses, and care managers caring for these patients showed:

• 86% reported improved understanding of the role and purpose of palliative care.
• 93% reported a better understanding of each patient’s wishes and values, which in turn informed the plan of care and treatment decisions.
• Respondents felt patients had a clearer understanding of their options and plan of care, and reported perceived improvement in patient satisfaction.

In short, this model produced measurable documentation gains, earlier advance-care planning, and culture change toward goal-concordant care without requiring a full dedicated palliative team on site.

Lessons Learned

First, you do not need a fully staffed palliative care service to deliver palliative value. A trained, empowered RN, embedded in multi-disciplinary rounds, resourced with scripting, and backed by a hospitalist-APP partnership, can dramatically expand access to goals-of-care conversations in a community hospital. This allows the specialty-trained palliative-care APP to focus on more complex cases and/or cancer pain management.

Second, early identification is everything. Building triggers into routine multidisciplinary rounds (less than 72 hours from admission; high-risk diagnoses; recurrent readmissions; functional decline) made consults proactive instead of reactive. When you wait until day eight to talk about what matters to the patient, you’ve already lost ground clinically, emotionally, and financially.

Third, standardization protects patients and staff. Using a structured template in the electronic health record means the patient’s voice is visible to every clinician. It also normalizes advance directive and code status documentation as standard care rather than “awkward” or “sensitive,” which reduces moral distress for staff and improves continuity.

Additionally, patient and family recovery hopes are often misaligned with available post-acute options. Candid discussions regarding post-acute care and discharge planning are crucial to bridge the gap between hospital and home.

Finally, language matters. Frontline teams often equate “palliative care” with “end-of-life care,” which can delay appropriate consultations. Deliberate re-education—“palliative care aligns treatment with the patient’s values at any stage of serious illness”—was necessary and should not be skipped.^12,13

Future Directions

The pilot demonstrated proof of concept: a hospitalist-designed, nurse-driven palliative care workflow can be stood up in a resource-limited community hospital and still deliver meaningful clinical, operational, and human outcomes. The next step is scale and sustainment.

Future priorities include:

• Continuing RN-led goals-of-care consults as a standard inpatient resource rather than a “pilot.”
• Formalizing referral triggers in admission workflows (e.g., embedding the “surprise question”: “Would you be surprised if this patient died within the next six months?”) to standardize early identification.¹⁴
• Expanding structured communication training (open-ended questioning, silence, best-worst-most likely framing) to hospitalists, APPs, bedside RNs, and care managers so that these skills are no longer rare or personality-dependent.
• Clarifying role boundaries so that routine advance care planning remains RN- or case-manager-led, while medically or psychosocially complex cases continue to escalate to an APP or physician with formal palliative expertise.
• Evaluating additional metrics such as length-of-stay impact and cost avoidance, which were not measured in this initial 90-day window but are expected to be favorable based on published literature linking early palliative engagement to shorter stays and lower cost of care.^2,3
• In short, the vision is to operationalize this as a standard of care, not a special project. 

Dr. Rai

Ms. Staton

Dr. Rai is vice president of clinical services and a hospitalist and physician advisor for AdventHealth Central Florida Division in metropolitan Orlando, Fla. Ms. Staton is the director of care transformation at AdventHealth Central Florida Division in metropolitan Orlando, Fla.

References

1. American Association of Colleges of Nursing. End of Life Nursing Education Consortium (ELNEC) website. https://www.aacnnursing.org/elnec. Accessed May 7, 2026.
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3. What is palliative care? Center to Advance Palliative Care website. https://www.capc.org/about/palliative-care/. Accessed May 7, 2026.
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13. Ushpol A, et al. Promoting early goals of care conversations in the CICU with a surprise question-based EHR workflow. BMC Palliat Care. 2024;23(1):288. doi:10.1186/s12904-024-01602-4.
14. Zaborowski N, et al. Early palliative care consults reduce patients’ length of stay and overall hospital costs. Am J Hosp Palliat Care. 2022;39(11):1268-1273. doi:10.1177/10499091211067811.