Advice for new hospice admissions RN

[NurseV32]

Hello Everyone,

I am a new hospice admissions nurse 2 months into orientation. My background is LTC, memory care, rehab. There are parts of this job I find incredibly fulfilling and meaningful such as being able to start providing the help families need when their loved one is facing end of life. I am proud to be part of an organization that can deliver meaningful services at end of life. I find however I am struggling with parts of this role that I did not anticipate and am looking for insight from anyone who has been in this position before.

I initially thought I would be coming into the lives of families and patients when the decision had already been made to start services and the patient had been deemed eligible for services by medicare standards. Essentially I would be in the position to start actually admitting patients.

I feel very confident and competent in gathering information that goes along with typical admission (physical assessment, signing paperwork, charting, ordering DME, medication input,etc). I am very thorough and detail oriented. I have always done well working with other people.

I am realizing however that my role will also frequently involve informational meetings which is where I am struggling. Often we go into homes with very minimal information (maybe just a name, number, and a diagnosis---no first cert even) and it is my role to assess a lot that is very psychosocial in nature such as is the patient ready? Is the family ready? How much do they know about hospice? Do they qualify for hospice? Are they meeting criteria/can they actually be admitted to hospice? Do they understand that their family member is EOL (that is really hard news to explain to a family if say the doc has not done the best job with it).What do I do if they are in need of help but I can’t provide them services because they don’t qualify? It’s a lot of pressure being alone with a family and not having answers. I find myself drawing blanks, feeling awkward, and very unprepared for some of these conversations.

The preceptor I am with is knowledgeable but has been doing this for a long time but is not necessarily a teacher. There has not really been any structure to these meetings that we go on---perhaps I just have to get more comfortable winging it and it will come with time. Perhaps I need to start “lesson planning” in a sense to feel like I have some idea of what to say and teach. Anyway I do have a heart for this work and would like to improve. Any insight is appreciated.

[Katillac, RN]

Congratulations on your new job! Hospice needs good nurses and your insights show that you have every chance of becoming a great hospice admissions nurse. I love that this early in the game you understand how complex the admission process really is, and are starting to see why. But there’s a steep learning curve. It’s too bad it wasn’t made clear how much of the job would be what’s often in social work’s wheelhouse. It’s too bad your preceptor isn’t meeting your needs for education. BUT in her defense, every admission situation is different, so it’s less formulaic as may have been for example, a long term admission.

A hospice referral stirs up all kinds of responses in patients and families. It’s everything from possible despair that the medical community has given up to them, to a hope that hospice will come in and “get it over” for them. It’s misconception that hospice will come in and provide 24/7 care, that TMBD (Too Many Birthday) is a hospice diagnosis, and that a hospice admission stamps the patient with an expiration date. The admission nurse is very much an educator, presenting a huge volume of information to people who often really don’t want to hear it for one reason or another. She's also often a mediator, counselor, translator from medical speak, and resource clearing house.

Some of the language I have found helpful includes:

• Starting with introductions, and then asking them what they know about the hospice referral and hospice itself.
• “All of us are on this rock for a certain number of days unknown to us. But the odds are that due to your circumstances, your number of days will be fewer than mine. Many people who are in your situation are no longer with us in six months. That’s not to say it will be true in your case; every situation is different. But hospice is a program that helps provide support to people who may be nearing the end of their life judging by certain criteria Medicare sets out. If you qualify, hospice can make this time in your life more comfortable and satisfying for you and your family.”
• “As I’m talking to you, I’m getting a sense that hospice may not be for you. (That could be for a lot of reasons: they don’t qualify, they need you but aren’t ready, family conflict over prognosis, religious concerns, you name it) But it’s hard work for a patient and their family when someone is seriously ill. You may want to contact one of these groups in your community and see if they have resources to help you through this time. (VNS, Office For The Aging, palliative care programs, your insurance company case manager)

The reality is that there are situations where additional help is desperately needed, for example custodial care of someone without a skilled nursing need, and no money for assisted living. In those cases, there isn’t much we can offer. It’s a HUGE crack in our elder/healthcare system. But reassure them that if anything changes and they would like to be re-evaluated for hospice they can call and start the process again.

I’d be happy to talk or DM with you if you have more questions, or if I can provide an ear.

[vampiregirl, BSN, RN]

Lots of great advice in Katillac's post!

I typically inquire what they understand about their diagnosis and it's expected progression. This gives me a barometer of their understanding (or unfortunately in many cases, their lack of understanding). I typically then transition into what their goals are. I try to relate this information into my explanation of hospice philosophy, benefits and services.

I often listen for misconceptions about hospice and address those early on.

Give yourself time to develop your own style. For me, as I figured out my basic template or agenda it helped me to figure out how to initiate more meaningful, less awkward initial visits. It does take time though! Good luck!