Going to Facilities

You may be dismayed at what you may perceive to be a lack of attention (or a genuine neglect) to your hospice patients. Once the SNF direct care staff become aware of hospice status, many times they incorrectly assume that hospice will be doing their showers, and all kinds of routine stuff (sometimes they do, sometimes they don't). It's an issue that really is never quite discussed, at say, staff meetings. Many nurses and CNAs are confused about a nursing home patient also receiving visits from hospice staff.

I found that to be true, where staff would actually save routine things for me to do that they were perfectly capable of doing themselves. Such as monthly catheter changes and blood sugar checks.

It irritated me because it took away from my time to thoroughly assess the patient's needs and made the visits exceptionally long.

Getting the staff to use the pain mess correctly. We usually give mess routinely so the patient's are comfortable. The staff does not understand the use of morphine for breathing. The idea of not feeding or giving fluids toward the dying. They frequently give fluids for hydration IV. Not attending education sessions when they are offered by hospice. When the facility gets these things it is a joy to work with and the patients due better.

They never call the doctor themselves and the most phone calls we get from facility staff are for patient falls.

Consider the facility your partner in providing care to the patient. Discover what their protocols are, your hospice should have a contract with any SNFs you visit. You will certainly discover some staff who are very interested in collaborating with you in the care.

Good luck!

I didn't mind doing the "routine" things like showers, cath changes and whatever (of course I did continuous care). In fact, I was happy to be able to give my patient all that care and give the overworked staff one less patient for that shift. Win, win baby!

My biggest beef with going to facilities was getting the patients' pain meds. I've worked in facilities and understand that the nurse may not be able to come IMMEDIATELY. However, when the nurse was standing at the med cart gossiping and I asked her for the pain meds only to return to the med cart standing in the same spot STILL gossiping while my patient was in agony, well, that didn't fly very well.

In private homes and assisted living facilities, you can give the pain meds but you can't in hospitals or LTCs (at least that is how it worked for me). That said, they are generally pretty good (I know that I was generally there within ten minutes when asked for pain meds regardless if it was hospice or not).

Good luck. Hospice isn't for everyone but I loved it.

Communicate with the nurse at the facility about changes or concerns. It always irked me when the hospice nurse came in for 10 minutes, left new med orders and disappeared.

I loved working with hospice patients when I was a nurse at a LTAC. However, I had 12-15 patients that required acute care, some with extensive wound care procedures. The hospice nurses would leave orders for their patients to receive morphine Q15-30 minutes as needed. There was no way I could assess a patient for pain every 15-30 minutes and dose as needed. Something to keep in mind when getting pain meds from the doc. In the LTAC and LTCs families and visiting nurses cannot give meds so it is all on the shoulders of the nurse on duty.

This is why it is important to have a collaborative partnership with the hospice team. The hospice nurse may not have any idea that your staffing may not allow that sort of plan.

Working with nursing home residents can be very challenging because of the preconceptions many of the nurses have and also there are variations in how hospices run things, so it's not unusual to encounter the complaint "But that's not how _____Hospice handles that!" or "But ______Hospice pays for that". I've encountered LPNs that refused to give morphine to a dying patient because they were "afraid to give them that last dose" and others that refused to give PRN pain medicine to a nonverbal patient because they could not ask for it. It's a political game to some extent because you are the ambassador for your company while you are there so YOU don't want to do anything to upset them because if the NH stops using your hospice company because of some perceived slight (your fault or just the way your hospice does run things), it's LOTS of $$$$ that will go to another company. If you happen to have several patients at a NH, I recommend you break up your visits so that you are not seeing them all in one day. They like to have a PRESENCE in the NH- let them see your face 2-3 times a week if not more. And good luck with your new job! I know you'll love it!

Try to educate the nurses at the facility as much as you can and empower them to get involved in end of life care. For the most part I have found LTC nurses to be caring and receptive to education, but they are usually stressed and over worked. A few times I have met a nurse who does not understand why you would give morphine for respirations...that is scary, but takes those situations as opportunities for education. Try your best to build a rapport with these nurses, because they can make your job much more difficult if they don't like you. Of course you will never be able to please everyone, but the worst thing you can do is have an attitude that you are better than them. I have been a LTC nurse in the past and felt that some hospice nurses have had that attitude so I try my best not to come off that way.

This is a good point, Stella.

We are not better than LTC or SNF nurses, we just have a different specialty and skill set. Just like they are not comfortable with my job, I would be terribly uncomfortable with (and probably bad at) their jobs.