One Clinician, Every Conversation: Palliative Care Delivery by Solo APRN Hospitalists in Critical Access Hospitals

Advanced practice registered nurses (APRN) who practice as solo hospitalists in critical access hospitals are often underrecognized in their role in providing palliative and end-of-life care. Palliative and hospice care specialty services are often not readily available for consultations in a timely manner, especially in highly remote areas of the country. These hospitalists routinely work without an option for palliative care consultations, ethics committees, or structured advance care planning processes. These hospitalists must simultaneously manage admissions, discharges, inpatient deteriorations, psychosocial situations with patients and families, and then carve out time to have empathic and meaningful end-of-life conversations. As a result, APRNs must independently deliver time-sensitive conversations, including goals of care discussions, health care agents' discussions, and end-of-life planning, in the hospital amid constant interruption, competing clinical priorities, and resource constraints. This article describes the full scope of the solo APRN hospitalist in a critical access hospital setting with close attention to how complex patient demands contribute to the challenges in providing high-quality end-of-life communications. This article examines clinical, educational, and ethical dimensions of this work, and presents a case example that illustrates how these pressures present during a shift. Strategies to strengthen rural palliative care capacity are discussed, including tele-palliative care, remote ethics support, and APRN-centered education. As rural workforce shortages persist and continue to rise, alongside rising patient acuity, naming and addressing these structural gaps is essential in improving quality of care and protecting the well-being of a solo APRN hospitalist.