Doubts about hospice

  1. I am new to hospice. I am perdeim. I am working essentially out of two different offices for the same company.

    I am not getting the best feeling from hospice. I cannot put my finger on it but I am not entirely sure anymore if this is what I should be doing. (Or maybe the company)

    Everyone is very nice. BUT. I just can't put my finger on it. I am not getting the education and information that I need. I feel left out of the loop. Though I have done everything to keep myself informed.

    I am presented with face sheets only on patients. It seems that I am to deduce everything by osmosis or mind reading.

    Maybe I am slow. My so called orientation took several weeks BUT was haphazard fragmented and very incomplete. I spent a lot of time during orientation just spinning my wheels and looking at the backs of my hands. When I suggested time could be better spent I was told not to worry.

    So here I am supposed (I guess) to know what I am doing and making mistakes. I can't keep one patient from another straight in my mind and it seems that I am expected to. Although I have seen many patients often only once or twice.

    I don't know from one day to the next if I will be working as they don't see fit to inform me. Yet I am supposed to provided them with a detailed calendar of my availablity.

    They are very nice BUT. I just don't know. I am unclear about what is and is not hospice criteria. Don't know how to tell which meds and treatments we are covering on a given patinent. On one pt. we may cover resp. meds and O2, and with another we may not.

    I just am not used to feeling this uncertain about something and having it work out. I was told by one nurse that I confided a little in to give it at least 6 mo.

    I don't want to job hop. I feel I am giving a lot a free time away, because of the way we have to do our time and travel reports.

    Help.
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  2. 15 Comments

  3. by   renerian
    Okay let me see if I can help you. Different hospice programs have different criteria for coverage. There are certain rules they all play by but each one is different. Some take vents, some do not. Some supply incontinence products some do not. Some take chemo patients, some do not. What I do is keep a folder on each patient to refer to, locked for confidentiality. That folder goes in the house with me. I keep notes on things I do/calls etc. I expect report on the days I volunteer. I go to team sometimes to stay abreast. Unless your hospice pays you hourly for things like drive and documentation time you are giving away free time. Same with home health. Do you go to team? How many days do you work? Do you take call?

    I can help you more with a little more information.

    renerian
  4. by   Agnus
    I go to team weekly although it is not required of me becasue I am per-deim.
    I try to keep information on everyone howwever it is getting very difficult as we are going paperless and I am the only one not on computer.
    We don't take vents, or chemo, the rules are pretty strict. If you want treatment you are taken off hospic. We don't even deal with tube feeding except to wean off. Or in such case the pateint is "hungry" and can't eat anyother way. Key word is hunger. We get report via a voice mail system and I have access to it 24-7.
    I am sitting here now not knowing if I am working today or not. it's 7:30 am. I have to sit on my thumb becasue I sssaid I was available. I am waiting on them to call to say if I am needed May be by 9 am I will have a clue. I have less of a life than I did working in the hospital or working as a HHA.
    Call is required. I get a wopping $5 an hour for that. I get paid 2 hours ant time and a half for going out while on call. BUT I must drive at least 75 miles and it take 3 hours for me to answer a call because of were I live. My night is shot if I must go out. They want the 2 perdeims to do call for the whole week. So far I am getting away with one day a week.
  5. by   Mandee
    That seems so unfair, you mean you get paid for two hours even if your visit is more than two hours?? Are you working for a large(national) hospice or a local hospice? I think it's awful they will not accept tube feeds, I mean sometimes families are just not ready for that yet. Also to expect you(and the other per diem nurse) to be on call all the time is not fair. Just my opinion but you might consider looking at another hospice in your area if that's an option for you.

    Mandee
  6. by   renerian
    I think your getting a raw deal. Hospice can be so good. Are you working for a for profit hospice?

    renerian
  7. by   NurseCrit
    I'm also new to hospice and I'm trying to find my way through. I was given one week orientation with another nurse and now I am out on my own. I ask questions frequently but sometimes I just don't know what to do. I always have to ask what medications are covered depending on hospice diagnosis. I have to be on call in a couple of nights and I'm getting very nervous about it. This is my first experience with hospice and home health for that matter. My patient load isn't that heavy right now. I'm trying not to be hard on myself and I realized in time all things will come but right now I'm not feeling the best. I would love to know of any books or assessment guides that any of you know about that would be of any help to me.
  8. by   aimeee
    Agnus, I think per diem is a very difficult way to begin your hospice experience, particularly if you feel you aren't getting the education and support that you need. 6 months is a normal amount of time to need before feeling TRULY comfortable with the job, but I think that the fragmented experience of per diem work may make it even more difficult since you won't be getting the feedback you normally would if you were managing your own case load. In your shoes, I think I would share my concerns with my manager and brainstorm and problem solve to see what can be done to help you be confident and successful in helping your patients.
  9. by   aimeee
    Nursecrit, this is an excellent book for guiding you through focused assessment:

    Symptom Management Algorithms

    Someone else had mentioned the A-Z Pocketbook of Symptom Control. I have not seen it myself but I have seen other references to it as being very helpful. You can get it here:

    A-Z Pocketbook of Symptom Control

    If your hospice has a relationship with a hospice pharmacy, you may also find that the advice of the pharmacists is very valuable and helpful.

    If you are at the home of a patient and are uncertain of what to do, you can call for help and still appear in control and confident with the family by saying something like "I have a couple of ideas about what would work best in this situation, but I would like to consult with one of my colleagues (or the pharmacist, or whoever) before I call for the order.
  10. by   Agnus
    Well I am feeling a bit better tonight. I saw 4 patients and claimed 7 hours. I was called in late and arrived at 10:30 this morning. So I guess that is not too bad. Two of the patients are close to dying. I was able to give some half way intelligent information to the families. AND I feel better because a patient that I saw a couple of weeks ago and gave some advice that was questioned by another nurse I now find was probably good advice.

    The pt. was being weaned off TF. Gettiing 1200cc of TF divided into 4X day. The family asked about cutting Free water. It was 200cc with each feeding. The TF was already cut 25% from the 1200cc. I suggested cutting the H2o proprotionately to 150cc with each feeding. I was asked what the calorie count was and that I should have not cut the water. (the primary had not yet met the patient and did not know the calorie count)
    Today She is completely off the TF and still on 200 cc H20 (the other nurse put it back to 200) The daughter said oner nurse told her it was too much. Today Her lungs were wet and she was starting to get edematose. So again I cut her and even suggested that if after cutting it the edema increases to consider stopping it all together. The primary wii be out sick for several weeks (that is who did not want it cut) The patient is probably not going to last more than a couple of weeks in my feeble estimation.
    I still question the significance of the calorie count of the TF if I was cutting the water proportionately to the amt of feeding that was being cut. It was proportional.
    If she were in the hospital and she was some one we were trying to save of course I never would have taken it upon myself to tell the family that they could cut back on this. This is hospice. And I have learned enough to understand that pouring fluids into someone who is dying will only start third spacing. I gave the daughter permission to stop it if she deemed edema was getting worse. It was only around one knee and one wrist right now. Coarse crackles in the lungs. Not real bad but definately a problem. Also she said that she coughed foam at times.
    That was a judgement that I was feeling bad about. I do not know how that nurse would feel now about the situation but I did what I felt was best. I am almost sorry I did not say to cut back more. But I perfer to move conservitively at first in making changes.
    Because this nurse will be out for a while and vacations I have been scheduled very well for the next 2 months. I am getting to know some of the patients which helps. It is really hard (like today) when I see a patient that I have never seen before and am asked if I think something about them has gotten better. Compared to what? Especially when I have not had a report on them and find them going through some things that should have but were not reported to me by the last nurse. Maybe there is hope.
  11. by   renerian
    Nursecrit a week of orientation is pretty crappy. Hubby says his nurses get 6 weeks of orientation.

    renerian
  12. by   TinyNurse
    I did 3 months with a hospice nurse!!! it was wonderful!!! I definitely want to do hospice nursing someday once I reach that "level of maturity".
    I don't know I feel you need a different level of maturity to reach these clients than in a hospital.
    I'm a new grad working ER/and pt in an alzhimers unit.
    I would definitely do hospice in this area someday.

    I do know that all hospices are different, so i guess it depends on who you work for, the nurse I worked with was super!!!! and seemed completely satisfied, she even wrote me a letter of reference.
    xoxo
    Jenni
  13. by   Agnus
    I am working in two diffrent cities both a consideral distance for me. I was only supposed to be working in the city closest to me. But I am filling in right now as the other one is short.
    Tonight I received a call from a nurse. She had talke to our boss because I declined to be put on call for Aug. I was told that I could not refuse to do call just because I was working in the other city (same hospice company, same boss over both) I was basically told We will all hate you if you don't take call. It has NEVER been an option not to take call and you have to.
    I will be handing in my resignation. It is so sad. I will talk to my boss about this but I will be leaving.
    I can see some real workable solutions that could benefilt everyone.
    Everyone is in LOVE with thier stress. They seem to get their sense of importace by how much stress they carry and how much they can self induce. The message I was getting we are miserable and we will not stand for anyone not being miserable along with us. She was so adament about this never being anyother way. It was like she wanted it to stay that way.
    I tried to explain that I was not asking for special privilege. That I was not a prima donna. I believe she heard, that I think I am special.
  14. by   aimeee
    Sounds like a sad situation, Agnus. Bravo to you for sticking to your guns and not allowing yourself to be stretched beyond the breaking point. I hope they wake up and direct their efforts at a remedy that will allow them to cover their bases without undue stress on their employees.

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