A Day in the Life of a Hospice Nurse

The author describes a patient visit and some of the lesser known aspects of being a hospice nurse.

A Day in the Life of a Hospice Nurse

I slung my computer bag over my shoulder and pondered the question one of my nurse colleagues who worked at the hospital asked me. She wondered what my typical day was like. I wanted to laugh because "typical day" and "nursing" probably don't fit in the same sentence. As I headed around to the back door of Mrs. J's house, the familiar gravel path crunched under my shoes. I knocked on the screen door and heard Mrs. J's daughter calling me to come on in. Mrs. J was in the den in the hospital bed, a real change from my previous visits when she had been able to get to the kitchen table and sip on her coffee while we talked.

"How was the yard sale?" I smiled at her as I took her hand in mine, feeling for her pulse. She had planned for weeks to have a big sale "so my kids won't have to do it." She smiled weakly at me, and said, "It went good. Got rid of a bunch of junk. I feel better about that." Then her expression changed to one of determination as she said, "I'm all set to go now."

I had been visiting Mrs. J for several months as she experienced a slow decline from her metastatic breast cancer. With her pain well managed, she had been able to continue to do many things she wanted to do: attend a family reunion, take her granddaughter back to school shopping, and watch her youngest daughter's pregnancy blossom. Her weakness, fatigue and shortness of breath had gradually become worse and now it was apparent that the final days were near. I tended to her needs, talked at length with her daughter and made sure everyone's questions were addressed.

When I got back to my car and finished up charting my visit, I looked ahead at the rest of the day-I had four more patients to see to try to wrap things up by my 4:30. I made some mental calculations about distance and priorities-always seeing the most needy first and those in institutions later in the day. I thought some more about my friend's question. How could I tell her what a hospice nurse really does? Some of it might really surprise her!

Hospice nurses don't generally go from one actively dying patient to another

Often, a hospice nurse, (also known as a Hospice Case Manager) spends her day seeing a series of patients that she knows, some of them for several months and in different stages of their disease. When a decline is gradual, patients meet the criteria of having a six month life expectancy but some of them live a little longer than that and some much less. Many hospice patients stay in the home setting the entire time they are in hospice. If there are symptom management issues they may have to go to a facility, such as a hospice house or a nursing home for a short period of time, always with the goal of going back to the home setting.

Hospice nurses focuses heavily and teaching and providing emotional and spiritual support

While there can be many technical interventions in the home: pain pumps, pleur-x catheters, dressing changes, wound management-these are not the focus of care but instead are tools to help promote comfort while dying. More interventional monitoring such as blood work, X-rays, scans, IVs and even pulse oximetry loose the center stage presence they occupy during the treatment phase of the disease process.

In the home, families and patients are a lot more in control

As hospice nurses we learn that we are there to provide the tools and the education but we do not force our way on the patient. From the very beginning, even during the admission visit, we tell patients that we are there to serve them; we want to help them have what they need in the home; we want them to know how they can call us and that we will come; but we spend much time teaching them how to respond to a variety of problems that might potentially come up. Being in our patient's home also puts a responsibility on them and the family in terms of agreeing to use their medications as prescribed. In these days of prescription medication abuse, we lay out clearly how the medications are to be given and then we explain that we will count meds at each visit to ensure they have an adequate supply.

Home hospice nurses visit patients at home wherever home might be

That can include nursing homes, assisted living facilities, group homes, retirement centers, apartments and regular homes that run the gambit from very modest to thoroughly grand.

A regular skilled nursing visit can take less than an hour

Or continue for several hours, depending on patient need. If there are serious symptom management issues then the nurse will often stay to make sure the patient is more comfortable and that proper interventions are put in place.

All the "other stuff" takes up lots of time

As in other nursing work, hospice nursing is heavily dependent on careful documentation, communication and one other factor-travel. In these days of bluetooth hands free cell phones, some of the talking to doctor's offices and home base can get done in the car, but making sure everyone is on the same page can take up a good part of each day.Knowing who to call and when to call are integral parts of becoming an expert in the field. In addition to daily communication, each week hospice nurses participate in Interdisciplinary Team meetings (IDT), a time when social workers, chaplains, administration, doctors and even families share information and work together to coordinate care. And of course, there is on call time. Most full time hospice nurses take some call, often scheduled once a week, an addition to a full schedule that can sometimes be difficult to cope with.

As I backed down Mrs. J's driveway, I carried some sadness with me. But I also felt a sense of accomplishment and peace because I knew that our team had done what we could to help Mrs. J and her family cope with and be prepared for this time of transition.

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jeastridge

About jeastridge, BSN, RN

(Columnist)

Joy has been a nurse for 35 years, practicing in a variety of settings. Currently, she is a Faith Community Nurse. She enjoys her grandchildren, cooking for crowds and taking long walks.

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Specializes in Hospice, Palliative Care.

Thank you so much for this post. I'm currently a RN student as well as a relatively new (since May of this year) hospice companion volunteer, and I was wondering what it would be like to be a hospice nurse. Your post answered a lot of my questions.

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I left the ER after 14 years to become a hospice nurse. I'm currently an intake nurse, but I do triage and weekly visits as well. I love my job, I really get to spend time with patients and families instead of rushing from one patient to the next, like I did in ER. Everyone is so grateful for everything you do. It's a very rewarding nursing field to get into.

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Heel

I have worked as a Hospice Nurse and liked it. I met some great people as well as co workers who were nurses or Care Managers. The article was informative and more detailed for me. Providing care differs with each individual because of the stages and gradual decline. I had a patient once who appeared to be like a sleeping angel when asleep, and when awake he only desired to watch westerns and had a smile all the time. They were still living in the real world but seem to have found total peace elsewhere, which is what I learned from a booklet a RN, DON wrote.

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Specializes in Adult MICU/SICU.

I've experienced hospice on the interpersonal end three times - all with family friends, who were more family than friend. All stayed at home, and I saw a huge difference between them and my professional counterparts - hospitalized pt's dying in a facility.

The differences were stark: all met the criteria, however the inpatient experiences were never defined as hospice, and most seemed to miss out on much of the quality of life features at the end (a few family members also changed their minds at the very last minute too, requiring us to perform full code/ACLS protocols when it clearly was not going to be effective, or a good outcome for the pt).

My father-in-law, also a pastor, explained the human death experience to me almost 30 years ago, after the death of my grandma. I was very close to her, and I suffered grievously, tormented by her loss:

"Death is something we all do collectively as a group, but in our own time. It is a different experience for each of us, all in our own way … but make no mistake, it's something we all will eventually do".

Between the two (home hospice -vs- inpatient) I certainly know which one I would chose - if I get the choice.

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There is a some evidence that says that doctors prefer to die at home in Hospice because they are much more informed about what is coming however:

"Research shows that most Americans do not die well, which is to say they do not die the way they say they want to — at home, surrounded by the people who love them. According to data from Medicare, only a third of patients die this way. More than 50 percent spend their final days in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in nursing homes."

But doctors have more control, are better informed, and can make better decisions concerning their death and how they want things to progress:

"When it comes to dying, doctors, of course, are ultimately no different from the rest of us. And their emotional and physical struggles are surely every bit as wrenching. But they have a clear advantage over many of us. They have seen death up close. They understand their choices, and they have access to the best that medicine has to offer."

Source: The New Your Time article: http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?_r=0

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Specializes in Faith Community Nurse (FCN).

Thank you for sharing! So true. Joy

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Specializes in med-surg, mother-baby, teaching, peds.

Loved the article on hospice nurse experience. I learned that even non-hospice home care shared many of the same attributes of nursing care approach. Keep writing as your perceptions are very helpful and enlightening.

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Specializes in Faith Community Nurse (FCN).

Thank you for your kind comment. Indeed, you are correct that hospice care and home health care share many of the same skills. While home care tends to focus on restoring and preserving function, hospice care centers on comfort and symptom management. Joy

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Specializes in PICU.

Thank you so much for your article! It gave me a lot of the insight I was looking for!

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Specializes in Faith Community Nurse (FCN).

So glad it was helpful! Joy

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