A Day in the Life of a Hospice Nurse

jeastridge, BSN, RN

I slung my computer bag over my shoulder and pondered the question one of my nurse colleagues who worked at the hospital asked me. She wondered what my typical day was like. I wanted to laugh because "typical day" and "nursing" probably don't fit in the same sentence. As I headed around to the back door of Mrs. J's house, the familiar gravel path crunched under my shoes. I knocked on the screen door and heard Mrs. J's daughter calling me to come on in. Mrs. J was in the den in the hospital bed, a real change from my previous visits when she had been able to get to the kitchen table and sip on her coffee while we talked.

"How was the yard sale?" I smiled at her as I took her hand in mine, feeling for her pulse. She had planned for weeks to have a big sale "so my kids won't have to do it." She smiled weakly at me, and said, "It went good. Got rid of a bunch of junk. I feel better about that." Then her expression changed to one of determination as she said, "I'm all set to go now."

I had been visiting Mrs. J for several months as she experienced a slow decline from her metastatic breast cancer. With her pain well managed, she had been able to continue to do many things she wanted to do: attend a family reunion, take her granddaughter back to school shopping, and watch her youngest daughter's pregnancy blossom. Her weakness, fatigue and shortness of breath had gradually become worse and now it was apparent that the final days were near. I tended to her needs, talked at length with her daughter and made sure everyone's questions were addressed.

When I got back to my car and finished up charting my visit, I looked ahead at the rest of the day-I had four more patients to see to try to wrap things up by my 4:30. I made some mental calculations about distance and priorities-always seeing the most needy first and those in institutions later in the day. I thought some more about my friend's question. How could I tell her what a hospice nurse really does? Some of it might really surprise her!

Hospice nurses don't generally go from one actively dying patient to another

Often, a hospice nurse, (also known as a Hospice Case Manager) spends her day seeing a series of patients that she knows, some of them for several months and in different stages of their disease. When a decline is gradual, patients meet the criteria of having a six month life expectancy but some of them live a little longer than that and some much less. Many hospice patients stay in the home setting the entire time they are in hospice. If there are symptom management issues they may have to go to a facility, such as a hospice house or a nursing home for a short period of time, always with the goal of going back to the home setting.

Hospice nurses focuses heavily and teaching and providing emotional and spiritual support

While there can be many technical interventions in the home: pain pumps, pleur-x catheters, dressing changes, wound management-these are not the focus of care but instead are tools to help promote comfort while dying. More interventional monitoring such as blood work, X-rays, scans, IVs and even pulse oximetry loose the center stage presence they occupy during the treatment phase of the disease process.

In the home, families and patients are a lot more in control

As hospice nurses we learn that we are there to provide the tools and the education but we do not force our way on the patient. From the very beginning, even during the admission visit, we tell patients that we are there to serve them; we want to help them have what they need in the home; we want them to know how they can call us and that we will come; but we spend much time teaching them how to respond to a variety of problems that might potentially come up. Being in our patient's home also puts a responsibility on them and the family in terms of agreeing to use their medications as prescribed. In these days of prescription medication abuse, we lay out clearly how the medications are to be given and then we explain that we will count meds at each visit to ensure they have an adequate supply.

Home hospice nurses visit patients at home wherever home might be

That can include nursing homes, assisted living facilities, group homes, retirement centers, apartments and regular homes that run the gambit from very modest to thoroughly grand.

A regular skilled nursing visit can take less than an hour

Or continue for several hours, depending on patient need. If there are serious symptom management issues then the nurse will often stay to make sure the patient is more comfortable and that proper interventions are put in place.

All the "other stuff" takes up lots of time

As in other nursing work, hospice nursing is heavily dependent on careful documentation, communication and one other factor-travel. In these days of bluetooth hands free cell phones, some of the talking to doctor's offices and home base can get done in the car, but making sure everyone is on the same page can take up a good part of each day.Knowing who to call and when to call are integral parts of becoming an expert in the field. In addition to daily communication, each week hospice nurses participate in Interdisciplinary Team meetings (IDT), a time when social workers, chaplains, administration, doctors and even families share information and work together to coordinate care. And of course, there is on call time. Most full time hospice nurses take some call, often scheduled once a week, an addition to a full schedule that can sometimes be difficult to cope with.

As I backed down Mrs. J's driveway, I carried some sadness with me. But I also felt a sense of accomplishment and peace because I knew that our team had done what we could to help Mrs. J and her family cope with and be prepared for this time of transition.