Advice for new inpatient hospice RN

tyvin, BSN, RN · Apr 9, 2017

Wow...pay attention the 5 weeks you got, ask questions and take notes. I'm surprised at how many new grads are getting first time hospice jobs. Where ever I have worked you had to have at least a year of experience.

Equip you car like a small mobile med/surg wound unit. Also, gloves, gloves, gloves. I find it easier on the clients with using a wrist blood pressure reader, an ear or forehead temp reader...things that make it more comfortable for the client. Of course, all that intrusive vital checks are stopped at some point when the client should be left to pass in peace.

If the person passing is bedridden: on every visit you make sure you visibly check their butt and back. The visits are a perfect time to reposition them...(make sure the family/staff is tracking the bowel movements: impaction can be extremely uncomfortable as well as decubitus ulcers).

I was taught this in school, in my quarter long clinical following the RN around for 3 months..I chose hospice. Can't remember exactly what the clinical class was called in my nursing program, but it was terrific. This was in my senior year; not the capstone and not the managerial quarter one (can't remember what that one was called either). That was many, many, many, moons ago.

Hospice is an acquired taste...it's not for everyone. My heart aches with love when I think of all the people I have waiting for me on the other side (other side could be many places since I have worked with an extremely diverse population; so enlightenment stage I'm coming! I'm actually getting my meditation down, I mean down...sorry: got off track there.

You need to be careful with the families at the homes. Once the decision has been made for the person to pass away at home, the family should be fairly well accepting and prepared (but...), quite often this is not so.

When it's been decided it's time to stop fluids, food, etc..., at the home, some family members will try things to keep the passing loved one alive; that may actually hurt the loved one who is passing. The family is frightened, terrified: they don't understand why taking away the food, routine meds and fluids at the end is a benefit to their loved one. This is the one of many aspects about home deaths, that has the ability to create big time grief for the family and staff if not handled correctly.

Since all families are different and there are so many aspects to the family dynamics there is not just one set of instructions on how to handle this as if there were an actual p/p of your facility (I'ld better be careful, someone just might have one).

Stopping routine medications, food and fluids is the hardest part of the process IMO and you should be teaching the family and client about the benefits of such moves for end of life care from the start...subtly is the word; subtly,

At that point many times the person passing is no longer verbally responsive and can say or motion nothing on the matter, which leaves the family members envisioning themselves as murderers for what they perceive as stopping care for their loved one. Early gentle teaching from the nurses, social services, chaplain or other hospice team members or family comes a long way later on. This will also be on their POLST.

Good luck to you and I pray your preceptor is a good person. So, working in the field or in the hospital? :up:

heron, ASN, RN · Apr 9, 2017

If you are working on an inpatient unit, you are in the ICU of hospice care. General inpatient care (GIP) is reserved for people with uncontrolled symptoms or those who are too complex to be cared for at a "lower" level of care. You will be getting many transfers direct from critical care units, possibly with complex wounds and families overwhelmed by catastrophic illness.

People coming from home will, by definition, be suffering from symptoms that are uncontrollable outside of an inpatient setting, including (but not limited to) pain, nausea, dyspnea and terminal agitation.

Both functional and dysfunctional families will be playing out their dynamics at the bedside, the family room, the nurses' station - likely for your entire shift.

The rewards are great ... but so are the challenges. Make sure you get to your interdisciplinary team meetings, even if you have to do it on your own time. Develope a relationship with - and pick the brains of - the unit's social worker and chaplain along with fellow nurses and docs. Get a good manual on symptom management (your md or fellow nurses can point you in the right direction) and make it your bible. Learn everything you can about every disease process that rolls through the door ... you will see it again.

Finally, stay aware of your own expectations because they are likely very unrealistic. Sometimes we help people go through a "good death" but more often we have to be content with making the process a bit less horrible than it would have been without us.

ETA: if you can, find the smartest, most experienced hospice nurse you can dig up and ask her/him to be a mentor. You are welcome to pm me with questions but in-person and on-site is much better.

nutella, MSN, RN · Apr 9, 2017

I could not agree more with heron about finding a mentor and agree with everything else.

In addition, I want to point out that since you are in a hospital you will have to learn 2 difficult things at the same time. First - you are learning to be a nurse - your professional role. And secondly, you will learn this specialty. It is a specialty that is not easy to learn as it is very involved and requires basically knowledge of all other disciplines as your patients will have different baseline medical problems.

There are also differences between palliative care and hospice care - it is not the same!

Here are my favorite resources:

HPNA

Core curriculum - the standard book.

this is our professional organization:

http://hpna.advancingexpertcare.org/

if you become a member, you get a discount on books and conferences ..plus there are many courses included ! I just took a new one recently and it was very solid. This is one membership that I find most valuable.

End-of-Life Care Resources | National Hospice and Palliative Care Organization

your hospital might be a member and you could have access to their member only resources but there is also information for free.

your hospital may be a member for

Palliative Care Training | Palliative Care Tools | CAPC

and they have great member only resources - some is for free.

As far as being a new nurse goes -

I think "hospice" will be easier for you to learn - in the hospital we typically call it "comfort measures only" or "care and comfort" or in some cases "general inpatient hospice" ( the last one when the patient is in the hospital but admitted by hospice under the medicare hospice benefit). Hospice is more straight forward - patient wants to focus on maximizing comfort, no curative treatments, holistic approach to address all needs. Always use a patient-centered individual approach to symptom control - to some patients it is acceptable to have some symptoms if they otherwise will be so sedated that they can not communicate - but the main point is to ask - not only about any symptom severity but also " what is acceptable to you?" patient or surrogate decision maker.

I have worked in the community and work in a hospital right now - many patients are being transferred if now imminently dying - hospice house, home with hospice, longterm care with hospice - dying in an acute care hospital is not optimal for many reasons.

Palliative care can be confusing and can be very hard to navigate for staff and patient/families. It requires a lot of time to get comfortable in that setting because the goal is not necessarily to maximize comfort 100% or to the degree somebody would want on hospice.

Typically, palliative care (not hospice or CMO) is best explained and understood as a "care approach" - it is not a separate benefit like hospice.

I usually explain it in the hospital setting as "serious illness support" or "serious chronic illness support" as patients typically have a serious illness but are still pursuing curative treatments that would be excluded under hospice. For example - a patient who undergoes most aggressive cancer treatment may need intense support and level of care but may be better served in a palliative care ICU - thought that sounds contradicting- as opposed to a regular ICU. That person may want to try the aggressive treatment in an attempt for cure or to get "more time" but also may want some aggressive symptom control and for sure needs spiritual and emotional support. A lot of times the family needs a lot of support as well - which is why palliative and hospice care is usually a team approach (MD, nurse, social worker, chaplain - perhaps volunteer or other therapists, depends).

It requires some practice to communicate around serious illness, end-of-life and to manage conflicts with families or between patients and their families. There are certain communication techniques that are successful, which is why you need a mentor who can help you to develop that skill.

What is special (especially in palliative care as the overall goal can be fluctuating) in any serious illness care and EOL care is the ongoing needs for self-reflection, self-development, and willingness to question your own motivation/view on ethics/view on humanity.

When the goal is clear (hospice/care and comfort ) and usually "peaceful death", "decrease and control of unwanted symptoms" and "family support" there is less ambivalence for nurses and other healthcare professionals.

In palliative care, there can be a fair amount of ambivalence and even transference/counter-transference. There are often conflicting ideas/interests. A good leader (nurse and MD) will be aware of that. We constantly have to look at our own bias as well.

The specific approach to patient-centered care based on values/goals/preferences becomes very important for anybody with a serious illness as there is no "one size fits all." And it is important to remember that we may have to support something that we would not want for ourselves.

A lot of stress comes from families especially with palliative care. There is a process that people go through when they have a serious illness. And it is not necessarily linear. A big struggle is when patient and their families are adapting to the reality of living with a serious illness and struggle with uncertainty. Many have a hard time coping when the outcome in unsure or they struggle with "making the right decision".

Because serious illness and EOL often lead to other "questions" like "is there a life after death" , "death preparedness" and so on you to be able to sit with other people's emotional and spiritual discomfort as well. And you need to be able to be comfortable with your own discomfort.

There are not always solutions and it is truly a process for most people until they finally die. Even though I might already know from the get go that this patient will die because I see clearly the functional decline, know the diagnosis and prognosis and so on - the family may be "surprised" and the patient may be not willing to talk about it or accept it. It sometimes causes a lot of emotional distress when patients and families insist on a "full code" when it does not make much sense. In those cases - I often tell everybody that there are some things we do not have control over as healthcare professionals. In my experience though - when push comes to shove - the patient and family in almost all cases change to DNR/DNI with aggressive symptom management. The rest that does not change their mind is a) futile and the doctor will not provide certain medical treatments (CPR is after all also a medical treatment) because the risk would not outweigh the benefit and the treatment only harm the patient; or b) ends up on a ventilator for example and if surviving some days may get trached/feeding tube and gets send to acute longterm care.

You do not always have to talk - there are situations when words would not be enough and a simple gesture is better. The other day a patient who had a endstage illness decompensated in the hospital and died shortly after the family arrived. Although the family was aware that the illness was not curable and the patient would die because of it at some point, it was still unexpected. Death is not always very peaceful in the hospital. In that case - all I did for a while was not speaking but just sitting there and holding the hand of the patient who had passed. I expressed "I am sorry that you lost your family member" and " It is hard to loose somebody close" and offered to call other family.

It will take some time until you feel comfortable as a new nurse and even more so in this specialty - you need to be patient with yourself. It has been my experience that most hospice/palliative care teams are close and very supportive of each others - hopefully that will be the case for you. It is a great area to work in - I am very happy with what I do.

Make sure you have a life outside of work - you definitely need a balance ! Make sure you exercise to get rid of stress/adrenaline (I do kickboxing), have a meaningful hobby (outside activities like hiking are great too), get your mind off work regularly ( I recommend to download a bunch of podcasts that have nothing to do with end of life or such - there are many great ones all for free like "the moth" "this american life", "TED radio hour", "radiolabs", "the new yorker radio hour" "inquiring minds", "Embedded" and "serial" --- they are so captivating that I immerse myself fully into those and take my mind off work. I listen to podcasts when I drive , when I wait somewhere, when I walk outside if I am by myself - I love podcasts). Make sure you spend time with your friends !

I hope things will work out for you!!

heron, ASN, RN · Apr 9, 2017

^^What she said^^ (and far more thoroughly than I could manage on my lunch break:dead:)

nutella, MSN, RN · Apr 9, 2017

^^What she said^^ (and far more thoroughly than I could manage on my lunch break:dead:)

lol - I am not working today ...

NursEmmy · Apr 9, 2017

Thank you so much for the advice! I am going to be on an inpatient hospice unit in a very large hospital. The unit is 24 beds with mixed hospice and palliative patients. They have given me a PowerPoint on symptom management and the medications ordered most often. I am mostly nervous about communication with family and helping them understand the end of life process while I'm just starting to understand it myself.

NursEmmy · Apr 9, 2017

I really appreciate your feedback. I will be starting on midnights and I'm hoping that will allow for more opportunities to ask questions. I have worked on oncology and hospice units as a nursing assistant so I have seen how families can be. I've also experienced the death of many loved ones recently and have seen both good and horrible deaths. I know I have the heart for this, it's just getting my footing. Thanks again!

NursEmmy · Apr 9, 2017

@nutella

i can't thank you enough for your response. In the next few days before I start, I'm definitely going to look into the resources you posted. I now have a better idea of the world I'm about to get into. I'm usually critical of myself to go above and beyond for my patients. I am aware that it will be extremely difficult to be at my usual level as I am finding my footing and I also need to be aware of burnout. Your advice to be patient with myself was invaluable. I love love some of the podcasts you listed.

Thank you!!!