Hospice help for in-home....

[karleigh]

Hello everyone, I am a home health nurse, but not hospice. My neighbors mother was just brought home to her house on hospice. She asked me to be there when hospice came, and I was, and wasn't impressed with the nurse that came out. She did not give them any information about what to expect, signs to see that may mean the end is near. I realize you can't really give a time line, but can any of you help me with what you would normally explain to a family about what to expect? I know cheyne stokes, and the organs will begin to shut down which will mean decreased output, mottling, etc., but is there any approximate time frame as to how imminent death is when these symptoms occur? I sincerely appreciate your help.

[tewdles, RN]

I can't speak to this specific situation, however, I do not always review signs or symptoms of impending death on the admission visit...unless there is evidence that the patient is likely going to die within the next five to seven days.

Given that the length of stay for too many patients is less than 10 days, we have these conversations early...but often not at admission.

Hospice generally has nurses who primarily admit patients and nurses who primarily act as case managers. That type of interaction and instruction is often left to the case nurse as that person develops an extensive and ongoing relationship with the patient and family. The admission nurse frequently limits education to the informed consent and those signs, symptoms, or issues which represent immediate need. Then the case nurse visits within 48 hours and develops the ongoing plan of care.

In all honesty, the admission visit is often lengthy and exhausting for both the family and patient (the nurse too sometimes) and it makes sense that if death is not imminent that such conversations would occur at subsequent visits. Most hospices provide written information which address the typical signs of decline and families are encouraged to review it at their earliest opportunity. I hope this was true for your friend.

Assigning a "time frame" for death based upon signs or symptoms status is more of an art than a science. Sometimes it is very clear cut, sometimes not so much...a great deal depends upon age of the patient, co-morbidities, and the "attitude" of the patient (some people come to hospice ready to die and proceed to do just that in a surprisingly rapid manner).

Typically, if a person is not taking any po nutrition they will likely not survive more than a few weeks...if they are not taking fluids 7-10 days is pretty common. Often people will experience a change in their level of consciousness and their ability to interact meaningfully with their family in the last 5-7 days of life, they may become restless, confused, agitated, lethargic, minimally responsive, etc.

The best bet is to speak with the hospice case nurse about the constellation of symptoms that h/she is observing and ask him/her to relate that to life expectancy. Honestly, this is one of the most frequently asked questions by families and the biggest question that we often cannot specifically answer. The minute I am convinced that a patient will die within 48 hours and say as much to the family...that patient will inevitably experience a "rally" and will live for a week...

I am sorry that you and your friend were disappointed by the initial visit. I hope that confidence in the hospice staff's abilities will grow as they have more interactions.

[Hospice Nurse LPN, BSN, RN]

Well said, tewdles! The only thing I can add is that the family is so overwhelmed at admit, doing EOL teaching at that time would be just too much. The exception would be that the pt is actively transitioning. Even with 5 to 10 days at admit, I would much rather do another visit for the next 2 or 3 days for additional teaching. Hope your friends family has a good hospice experience.

[ErinS, BSN, RN]

I definitely agree with the previous posts. I have actually worked doing admits and case managing. When I was doing admits I often would do the follow up visit the next day. I learned early that I could spend an extra hour going over symptoms and signs of dying on admit, but that the next day it was totally forgotten. I have since not discussed that in admit unless someone is actively dying or they ask me about it.