3 Hospice Case Studies: LTC Facility, Hospital, and Home

Hospice care happens at home, in the hospital and in LTC facilities. In the 3 case studies described, the author discusses different focuses for patients and families who are referred to hospice.

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3 Hospice Case Studies: LTC Facility, Hospital, and Home

Hospice: 3 Ways

Hospice at the end of life is focused on the whole person and their needs for symptom management, their psychosocial needs as relates to their significant others, and their spiritual care at the end of life. In these three case stories by a Faith Community Nurse, we see how hospice can be about much more than simply physical comfort at the end of life. A hospice team composed of nurses, aids, social workers, administration, chaplains and more, can play a part in helping the patient and family to the point of death and beyond.

Hospice nurses work in different settings, often during the course of the same day, often visiting in a home, then in a nursing home, hospital or an assisted living facility. Sometimes facilities do develop a preference for one hospice agency over another, but according to the law, hospice agencies are to be presented fairly by case managers, physicians and others who have an opportunity to refer to hospice.

1. Hospice in the Nursing Home

There are some nursing homes that resist hospice care. Since hospice services are included in Medicare, it is difficult to understand why there would be any resistance. Nursing homes often do a great job taking care of patients in rehab and those who are under long term care but most could benefit from expanding their care to include hospice expertise as the end of life approaches. (The Gerontologist, Vol 46, Number 3, p325-333)

The FCN, Stephanie, caught up with Edward as he walked along the sidewalk with his walker outside the assisted living facility. After exchanging greetings and small talk about the weather, she asked him how his wife was doing. Mary had been suffering from Alzheimer's Disease for several years and had experienced a recent decline with a significant loss of interest in her surroundings, as well as diminished energy, appetite and less recognition of her family and caregivers. The family had called in their Faith Community Nurse to discuss hospice but found that Edward was hesitant to take the step.

As they walked along on the late Summer afternoon, enjoying a cool breeze they talked about Mary's condition. He said, "I think she would do better if she tried harder. She just needs more stimulation.” The couple had been married for over 60 years, and his longing for her, and the grief that he was already experiencing at the thought of her impending departure from this earth were clear.

Mary lived at an adjacent nursing facility so they kept moving in that direction as they talked about the recent changes. "Edward, I know your family has been talking about hospice. Are you interested in talking about that? Are there any questions that I can answer for you?”

"I don't want to do that!” He exclaimed with a flash of anger. "I want to get her into rehab. That would help more than anything.” She let the topic go for the time-being as we finished the short walk and headed into Mary's room.

In subsequent days, as Mary continued to decline and spend more and more time asleep or unresponsive, the path forward became even more clear. His daughter said, "The facility is managing the end of life symptoms well, but we need hospice for dad. Hospice might give him the support he needs to change directions and let her go.”

The daughter brought up the excellent point that sometimes hospice is as much for the family and the staff as it is for the patient. Sometimes there are minimal symptoms to manage, and physical problems are not the primary concern, making the support for the family a priority.

Also, in a situation with a long-term resident of a nursing home, the transition to hospice can help everyone at the facility change directions to a more palliative care frame of mind with less interventional care considered. Hospice can assist the patient, the family and the facility in being on the same page.

2. Hospice in the Hospital

Shirley had experienced a difficult year:a broken hip with a stay in a rehab facility, another fall with broken ribs and pneumonia, chronic pain from degenerative changes, diagnosis of atrial fib with anticoagulation therapy, a loss of mobility and function as well as a loss of many of the activities she enjoyed in life. Her husband, Carl, was a diligent caregiver, installing ramps, assistive devices, chair elevators and much more, to make their home navigable for her. In their mutual devotion they faced each day together, not without frustration but generally glad to have more time with each other.

Their FCN provided support, helping to coordinate their congregation's attention so they it decreased their sense of isolation and helped them to stay involved as much as possible.

After a long stint in rehab, Shirley was finally getting out and about more and beginning to feel a little more like herself when one day she felt sick to her stomach, vomited blood and passed out. She was rushed to the hospital where she coded and was placed on life support. Her husband knew that she did not wish to have advanced interventional care but at the moment of crisis could not face "letting her go,” as the staff said.

After several days on a vent with valiant attempts to prolong her life, it became abundantly clear that the end was near. The medical staff talked with Carl and the children who had gathered. They wept and mourned there in the ICU as respiratory therapy came to disconnect the ventilator. The FCN was with them and tired to provide information, assistance and support.

Shirley continued to breathe after the discontinuation of life support so she was transferred to a hospice unit where their professional help aided the family during the time of transition. Shirley continued to receive optimal symptom management for respiratory distress before passing peacefully a few days later with the children and her beloved, Carl, standing at the bedside.

Hospice in the hospital plays a strong role in helping make death easier and in bringing everyone together as they transition from the hyper-active interventional mode to the slower pace of accompanying someone who is on their final journey. The hospice team during this time can help the family who may struggle with how the whole end of life process has gone and who may worry about whether or not they have done the right thing in choosing hospice.

3. Hospice at Home

The FCN got a call from the family. Arnold was ready for hospice care. After a 2 month battle with metastatic esophageal cancer, he and his wife were ready to change directions from interventional care to comfort care and hospice. His cancer, found in an already advanced stage, threw out complications faster than they could be addressed and brought under control so that he could qualify for any type of therapeutic regimen. After dealing with hypercoagulability that brought about ischemic pain in his feet to breathing problems related to tumor growth, they realized their time was too short to spend it in the cramped bays at the emergency room. He wanted to be at his country home, enjoyed the views from the front window, basking in the warmth of family and friends during whatever time he had left.

While 27% of hospice patients are in a facility, 66% participate in hospice from their own home. (2013, National Hospice and Palliative Care Organization) Home care is truly the most common model of hospice care and when engaged early enough, allows for the time for the organization to fully deploy its range of helpful care options.

After visiting with the family, the FCN let them know how to initiate hospice services with the company of their choice, smoothing the way for hospice care to come into the home after a referral from the primary doctor.

Hospice at home, in the hospital or in the nursing home can serve the patient and family well as they look for ways to help everyone involved come to terms with the separation caused by death.

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jeastridge

About jeastridge, BSN, RN

(Columnist)

Joy is a long term nurse who has worked in a variety of settings. Currently, serves her congregation as a Faith Community Nurse. She enjoys writing and has published a children's book and two Bible studies.

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Specializes in Hospice, Palliative Care.

Depending on our agency's census we have anywhere from 80% of our patients being home patients, to as high as 90%. While I see patients where-ever they live (home, ALF, SNF, hospital under GIP), I prefer the home-patients. They tend to be the most challenging and rewarding.

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Specializes in Hospice.

I like the facility patients. With the demographics in the area I work in, patient safety, adequate caregivers are a constant headache. In the facilities, I know their meds are managed correctly and patients are safe. I enjoy the team work and collaboration with the facility staff and generally, can manage patient care without worrying that the caregiver will fall over dead from strain and their own health problems before my patient does.

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