Help for the new hospice nurse please

westieluv · Nov 26, 2014

Well, I understand it to work like this: If a patient lives in a LTC and is not eligible for Medicaid (which pays their room and board regardless of if they are on hospice services or not) Medicare will pay either the hospice benefit or the room and board at the LTC but not both. This means that if the patient and their family opt for hospice services, their room and board becomes out of pocket. As a result, those patients will either opt not to sign on to hospice or they will opt to sign on to hospice and go home to die. Obviously, the LTC management do NOT want to see residents (and their Medicare dollars) leave the facility, so that alone causes some tension. The nursing staff is not directly affected by this, so they don't care and that's probably why they are nicer to you.

Sometimes the staff in LTC facilities do not like the way that hospice is managing the patient's care. Case in point: one of the nurses at a hospice where I used to work had a LTC patient who was actively dying and having terminal secretions. Per our standing orders, she ordered SL Atropine drops. The nursing staff was too busy to give them q 2h as ordered, so they complained that they weren't working. One of the nurses questioned the use of the Atropine, stating, "Well, Hospice ABC uses Scopalamine patches. Those work much better." Well, maybe they do work better in that the staff only has to change them every couple of days, but this man had active secretions and difficulty breathing and Scop patches take several hours to take effect. Our nurse explained this, and stressed that the staff needed to give the Atropine as ordered, but the next day when she went back to do the death call, the patient had a Scop patch behind his ear because the LTC nurse had gone over her head and gotten the order from their medical director, in essence overruling the hospice care of the patient which really negates the need for hospice if they aren't going to trust the hospice staff to know what they're doing.

I think it's a combination of money issues with the management and an overall lack of understanding of the hospice philosophy and the role of hospice staff on the part of the LTC staff.

PomMom65 · Nov 27, 2014

I have also seen situations in LTC where they are just not comfortable giving the medications and dosages that we give. I think it is a lack of understanding the hospice philosophy as well.

Kittypower123, BSN, RN · Nov 27, 2014

All the things mentioned above are good points. I think it's important as well to involve the nurses at the LTC in the decisions about changes to POC and/or meds. They know what's going on with the patient and don't want to feel like their being judged, or somehow not doing everything they can and should. We're all on the same team and we need to make sure they know that. They should feel supported, not pushed aside.

In regards to situations like the terminal secretions, I advocate for crisis care if the symptom is more than the facility can manage. Just because they are in a facility doesn't mean that crisis care is not appropriate. Even if I can't get it approved, the nurses at the facility know that at least I tried.

I've been on the other side - before I went into hospice I worked in LTC. The hospice nurses that came to the facility from the company I now work for were always great. They made sure that I was on the same page with changes, kept me in the loop with information I might need to know, and tried to make things a little easier for me. I knew that I could contact hospice and get some support when something came up.

LovelyLu · Nov 27, 2014

Thank you for the replies! It helps me put things into perspective. When I had originally shadowed/interviewed for this job I was confused about the hospice nurse's role. I did not understand why a facility full of nurses would need a nurse from the outside to help care for someone. Now that I have become a hospice nurse I am so thankful for what I have learned.

ktwlpn, LPN · Nov 28, 2014

Cultivate a new relationship with each LTC. Introduce yourself to management and unit nurses,obtain their protocols and work WITH them. Offer to inservice staff (either formally or on the unit) and teach as you go. Paper compliance is vital,also make sure you inform the staff on the unit after you speak with the resident/family. Obtain the facility phone directory and email addresses, if possible find out the names of the nursing and support staff on each unit.