Coney Rarey, RN
Palliative Care of CMC-Northeast
Questions
Could you start by giving some brief
information about yourself? What do you
do? How long you been an RN? How
long you have been at palliative care?
What all types of services do you offer at
your facility?
Answers
My name is Connie Rarey, and I am a
registered nurse here at CMC-Northeast. I
work half time with Hospice & Palliative
Care of Cabarrus County and half time with
Palliative Care at CMC-Northeast. I have
been a nurse for almost 31 years. I have
been a nurse in hospice for 10 years and a
nurse in palliative care since September
2009.
Palliative care is a supportive group. We
have 3 total nurses, 1 social worker, and a
nurse practitioner who just started. It is
nurse driven at this point because a nurse
practitioner or physician has not been
overseeing palliative care. First, we attain
an order from the physician, and then we
provide consultations to the patients in
need of our services. Much of what we do
is provide support to the families,
reviewing patient’s charts, and assessing
what family/patient knows about the
illness. Patients/families tend to be poorly
informed about the illness therefore we act
as the intermediary to help them understand
how the illness is and the prognosis is the
illness and prognosis, and often it is end of
life. Even though palliative care can
extend years before end of life for a patient,
I believe the trend is lack of education and
referral to our services. We are often
seeing end of life issues, and many of our
patients are actually eligible for hospice.
We are trying to help these patients goal set
by analyzing the situation and explaining
what is going on, as well as providing them
information regarding their options. We do
try to explain to patients that curative
treatment is not the only option and
comfort is desired this is an option as well.
We try to help them understand advanced
directives, CPR, and what living wills are
all about. We try to inform our patients

What is the average number of day’s
patients stays on palliative care?
What is the primary population that you
care for?
What is the most common admitting
diagnosis of your patients?
What do you feel is the cause for this?
Do you feel that there are environmental
factors that contribute to these diagnoses?
How are your services funded?
what physicians are trying to say and we
try to analyze what physicians are and are
not telling the patient. At times, we have to
bring doctors into the room to really sit
down and be honest with the family. Social
workers do the same thing; however, they
focus a lot more on social issues then
nurses.
We follow patients throughout their entire
hospitalization. At times, we get patient
referrals and they die before we can even
get to them. We cannot provide an average
number of days for the patients we care for
because we do follow them throughout
their entire hospitalization. We may have
ICU patients from 7-10 weeks before they
die or are discharged.
The population is broad, ranging any were
from very young to elderly. I would say
50-75% of the population is geriatric
patients. In the ICU, we tend to see
individuals of various ages. Recently we
have had many 40-60 year olds.
Everything, there are no specific diagnosis.
There is not really a trend I guess much of
what we see is a multitude of co-
morbidities. Sepsis is one of the primary
diagnoses of our elder population. This is
often due to a predisposing factor such as a
UTI or pneumonia.
Just old age, their immune system cannot
fight off these diseases. UTI’s are the
biggest issue with the elderly as well as
aspiration pneumonia. I would say 50% of
the elder population has an issue with
aspiration.
This is hard for me to say. Many issues
may be due to smoking and an unhealthy
diet. In this general region, tobacco is very
prevalent. I think that this area has a
tendency to have issues because of
smoking and the southern diet.
We are not. We are a supportive group.
When the nurse practitioner and the
physician start working with us they will

North Carolina State Center for Health
Statistics now lists heart disease as the
primary cause of death compared to 2008
when it was cancer, have you seen any
change in the number of patients with heart
disease?
What is the most common admitting
diagnosis of the younger patients you
serve?
Are there any similarities associated with
the patients with the major diagnosis you
have identified?
When you are trying to attain palliative
care for a patient what is the primary
issue/barrier when trying to do this?
have billing access and will be able to bill.
As nurses, we cannot bill for palliative
care. At this point, we are just a service
that the hospital feels is necessary. We
hope that evidence will show we are
decreasing the number of readmitted
patients, because many of the patients are
being referred to hospice.
No, I do not think so because we see a great
variety of things. There are just so many
co-morbidities.
Since I have been here, we have not had
any calls for young children or
adolescence. The few times that palliative
care provides services to young children is
in the NICU because a child may have been
born with a heart abnormality.
No, I think pretty much across the board
there is no one particular group.
I would say the misconception of palliative
care is a big issue. A lot of patient’s think
that we are hospice and this is not true. In
addition, the lack of education, promotion
from physicians regarding our services is
also a big issue. Many physicians think
that when they order palliative care they
have ordered hospice services. We want
doctors to understand the difference
between the two services. In addition, now
that I have joined and I use to be with
hospice physicians are often like “what hat
are you wearing today?” For example, last
week the doctor called and said, “I got you
two new ones to see,” when the
information for each patient never came
through to the printer I went upstairs to
check the order and both of the patients
were hospice patient’s not palliative care.
Therefore, I would say a major barrier is
trying to get physicians to understand that
palliative care is part of end of life but it is
a broader spectrum.
Does palliative care have a specific criteria
patients must meet in order to receive
services, similar to hospice?
What other services are available to the
palliative patient community to supplement
your services?
Are your services limited to patient in the
hospital?
What services do you see patients/families
utilize most?
What are the top three concerns/problems
for the patients you care for?
Are there services that many palliative care
patients needs that your organization
cannot provide them?
What interventions has palliative care
implemented to address these problems?
Are there any interventions you have put
into place to address these issues?
Are you seeing any changes to the number
of referrals to your services as a result of
Palliative care sees anyone under any
spectrum of care. In addition, as I
mentioned before, a large majority of our
patients are hospice eligible. Again, these
patients are not captured early and we do
not have a community based palliative care
program.
Our social worker refers patients to outside
community services. For example
counseling services and funeral homes.
Yes. At this time our outside program is
not up and running but when it does it will
be driven by the nurse practitioner and
billing abilities will exist.
Funeral services because patients are
referred so late.
Late referrals are the biggest thing, not just
for us but hospice as well. The majority of
the patients we care for are in the last year
of their life, and some are in the last few
days of life. Misconceptions that the
families/patients have about palliative care.
Many patients think hospice when you say
palliative care and this is why it is so
important to educate them about the
differences that exist. Physicians just not
having totally appropriate knowledge of
how to make the referral and when they
should make the referral to palliative care.
The community services. For those that are
doing fairly well if we could provide them
with community services and have the
ability to care for them in their home.
We try to do lots of education. Any time
we got the opportunity to talk to the
physicians we try to explain what the
differences are between hospice and
palliative care. Just information, lots and
lots of information.
It is an ongoing educational thing. Dr.
Allen from hospice is supposed to assist in
promoting our services. We have had some
in-services and Dr. Allen has been assisting
a lot with everything.
I think the referrals are probably overall
about the same as last year. On the average
these efforts?
Are there any similarities that exist
regarding the patients you see (such as
race, religion, or demographic area)?
Does your facility use healthy people 2010
as a reference?
Is there any community outreach programs
designed to educate people about palliative
care or other services allocated to
death/dying?
Is safety in the home a concern when
caring for patients?
Is lack of access to care an issue?
Is inability to pay an issue with the
community to serve?
day we see about 25-30 patients and that is
a lot in one day. Just yesterday, we got 12
new referrals. With each patient, we have
to sit down and read the chart and
investigate about the patient. I do not think
that numbers have changed drastically. I
know in 2008 we saw approximately 1,000
patients from the palliative care
perspective. It is hard to tell that our
efforts are making a huge impact.
We see a lot of nursing home patients;
about half of the patients we see are from
nursing homes. A lot of these patients have
chronic illnesses, such as UTI’s, diabetes,
CHF, pneumonia, aspiration, dementia, and
other co-morbidities
We do not utilize the document.
Not at this point in time due to the lack of a
community based palliative care program.
Falls are a major issue. When I think about
safety issues, I think of dementia because
of confusion. A lot of elders refuse to live
in a nursing home or go to a facility and the
families have to work therefore no one is
there to assist them throughout the day.
I do not think its lack of access to medical
care. I think there are many physicians in
the area and the emergency department is
also available. I think maybe lack of
knowledge is the biggest thing; they tend
not to know what to look for or when to
seek medical care. When they actually go
to seek care things tend to be really bad at
that point.
Yeah, I think so because in the last year or
so many people have lost their jobs and
they don’t have any financial way of
paying and/or the family feels stressed
because their family member is ill or needs
care and they cannot afford to quit their job
or the patient doesn’t meet the criteria to go
to a skilled facility. We see families just
absolutely torn to pieces trying to figure out

Are there any issues with attaining
medications?
If you could change, any component of
palliative care services what would it be
and why?
Do you collaborate with other programs or
facilities?
Is there anything else you would like to tell
me about palliative care?
how to care for family members.
I do not deal with that aspect of care. Case
management deals with a lot of that. Our
social worker has helped families tap into
other community resources such as
Community Care Plan or the Veterans
Association. If we see that financial issues
exist, we have the social worker go in to
work through those issues.
Well, I would definitely change the referral
mechanism and try to provide our services
to patients earlier. This will be changing as
the nurse practitioner and the physician
participate in our services. They will be
able to work more closely with the
physicians and address issues like the
discontinuation of life support and things
like this.
The hospice programs, we make referrals to
other hospices not just Cabarrus County
based on where the patient is located. We
collaborate with the hospice liaisons as
well. We do this fairly regularly. There is
a lot of collaboration between palliative
care and case managers.
I think it is an up and coming program and
I think you will be seeing more and more of
our services. It is just a lot of support and
education and we also get the time to spend
a lot more time with the patients compared
to the physicians, letting the patient talk
about what is going on and trying to help
the patient sort through the illness and
outcome.