Care at the Time of Death - page 2
from ajn, july 2003: care at the time of death how nurses can make the last hours of life a richer, more comfortable experience. by elizabeth ford pitorak, msn, rn, chpn ... Read More
Aug 18, '07You can do that by being empathic in taking care of the patient and family.'The golden rule'.
Aug 19, '07Leslie, I was complimenting you (or trying to), I enjoy reading your postings, you come across as knowledgeable and wise.
Michael, no doubt that you think about the things you write; when I first got into Hospice I came across your "Crossing the Creek" and it was a Godsend. It helped empower this dummy, bad things may have happened faster, but good things have prevailed. Thank you! Please don't disappear from this Forum!
Leslie, you mentioned in a posting that you were working inpatient Hospice. Is this a change? If so, how does it compare to outpatient?
Do you have more or less time to help your patients work through the dying process?
Michael, I'm will try harder to comprehend your messages, as there is much wisdom and truth to what you write. I employ the K.I.S.S. (Keep It Simple Stupid) method, so please be patient.
I agree with your assessment about Nursing and the Nursing shortage,
and the frustration of not having the time (or afraid of taking the time)
to care. It is usually easier (less confrontational) to quit, than to try to persuade others the proper way; because, they (administration) only relate proper to profits.
I also agree with your critique of the article, and your concern with the
academia (aka "experts") definition of "death", and their failure to address the issues of life transcending death; maybe due to those restrictions of time that we impose on ourselves.
Michael, your message is getting through, keep it coming.
Aug 19, '07Allow_Mystery…
That is an intriguing name by the way. I suspect Native American or Metaphysical influence.
My disappointment with the author of said article is its low intellectual level. If you go to the trouble of getting a Ph.D. why teach third grade? Why not teach grad school… or perhaps even do some meaningful research?
For example, in a previous thread I brought up the following point (but for whatever reason it got lost in the shuffle.) It has been my experience and observation that people can move on (die) sooner (and easier) if they get their work done. In other words, when you have finished, you may leave.
By “finish” I mean: Dying process is largely resolutional in nature; i.e. the task is to resolve one’s unresolved issues. When that work is finished we say things like- “He seems at peace now.” Therefore, to get at the real core of assisting the dying, to truly be helpful to them, we must focus on helping them to resolve their unresolved life-issues.
Instead, what I see happening in hospice more and more is focus on “comfort.” DON’T get me wrong… focusing on comfort is a good thing. Hear me say that. BUT (and this is the BIG BUT) if the focus is on comfort to the exclusion of assisting with resolution, then the net result will be to extend… as in- lengthen… the dying process.
In other words, the current trend in hospice appears to be heading in the direction of keeping patients alive longer so as to increase revenues (keeping them comfortable, chemically sedated but NOT assisting them in the core task of dying process; i.e. the resolutional work.) Because hospice is paid a per diem, the final result is: hospice makes more money by NOT doing its job… by dragging death out… by encouraging patients to linger instead of helping them get their work done.
This is the kind of thing… it seems to me… that would be worthy of a Ph.D.’s time & attention (as opposed to rattling off minutiae to impress rookies.) If hospice is beginning to veer off track in the direction of victimizing dying people for profit, I think that should be nipped in the bud… pronto! And it is hard to reach any other conclusion when one considers that assisting people in the resolution of their unresolved life-issues takes time and intimate interaction between nurse-patient-family… then looks at some of the threads in this forum which address the loads that are being dumped on nurses. I have to tell you that when I read through some of those threads it is truly disheartening.
Unfortunately, the majority of hospice reimbursement is set up on the capitation system, which basically comes down to: The less the hospice agency does for the patient, the more money they make… literally. I am not kidding… the less service the hospice provides, the more money they make. Let me restate that in yet another way so as to be absolutely clear: Hospice agencies are rewarded (financially) for doing less. So increasingly we see nurses quitting because they cannot even meet minimum requirements, much less have the time to sit with a patient… for HOURS PEOPLE!!!!! Not just a minute or two to adjust a med regime. You don’t resolve unresolved life-issues in a minute and a Haldol… it just doesn’t work that way. And if you are not helping patients resolve their unresolved issues you are dragging out (extending) their dying process for profit.
This, it seems to me, is urgent. Certainly it is more urgent than impressing rookies with minutiae.
And by the way Leslie…
You are so well thought of around here that any time you speak everyone stops to listen. Some others can rattle away and no one pays much attention, but when you speak everyone falls silent and listens. And I love your sense of humor… it is about as goofy as my own.
I did chuckle at your comment about my having too much time on my hands. There is more to that than you realize.
Thinking actually does take time. It’s funny, but I often hear nurses say things like: “I have next week off. Thank God! I really need to unwind.”
Let me tell you something, when I got out of the rat race, do you know how long it took to unwind? About a year. You really do not have any idea what the rat race is doing to you… until you have been out of it for some appreciable length of time. Until then you really don’t have time to think.
So I read (in this forum) what y’all are going through and it makes me heartsick… it makes me want to cry. Some of you are so incredibly good at what you do! But because you are still in the midst of the fray… still in the trees where you cannot see the whole forest… there are times when I am in despair for your well being. Then when some self-serving school marm of a Ph.D. starts wagging her finger in your faces, something snaps and I go a little crazy. I want to get in her face and yell, “You don’t have the right to talk to these people in that tone of voice! DO NOT talk down to them. For crying out loud, Leslie has more knowledge about dying process than you and all the people who granted you your Ph.D. ever imagined!”
Aug 19, '07Michael
I see the Hospice trend toward home health, and not end-of-life care;
therefore, Hospice nurses are being required to be diagnosticians, lab technicians, and physician pansies. We simply don't have the time to tend to the matters that are important to the patient that may be in the dying process.
Also, with the Hospice trend towards home health, caregivers and families are so much in denial, they simply won't allow you to focus on the important matters of death; they demand aggressive treatment of all symptoms, and since they want instant results, we're not allowed the time to resolve the real issues.
Just some of my thoughts, I'm sorry if they don't fit in to where you are trying to go.
Aug 19, '07Allow_Mystery…
As you know, I am not involved in hands-on hospice any more… and have not been for a long time. So I don’t really know, from that perspective, what’s going on. You are the expert there.
Moving towards Home Health? Hm-m-m-m. That puzzles me. Why?
Aug 19, '07Michael
for the same reason you suggest we are prolonging life with medication .... the bottom line. Medicare has cut way back on the monies for home health at the same time raising the per diem for
Hospice, home health businesses have declined, Hospice businesses are now on every street corner ..... follow the money; and since we now have so much competition, and the good old boy and girl physicians want good care for their patients .... care they no longer can get from home health, they are utilizing Hospice for this care ..... and we are being told to admit patients without Hospice criteria ..... as case managers we are being railroaded ..... for the bottom line. Hospice is on a very slippery slope right now.
Aug 19, '07Allow_Mystery…
Oh… I see. My! That is interesting… or should I say- scary?
Is this trend general? Across the board do you think?
Aug 19, '07Michael
I've seen it across the board in this area. I understand that the
State has recently put a moratorium on Hospice licenses, but looks to be a little late, the creek had already arisen to uncrossable levels (I thought you may appreciate that analogy). Will be interesting to hear from others!
Aug 19, '07to avoid legal ramifications of the slippery slope, many hospices are adding palliative care benefits, thus broadening the scope and length of services.
Aug 20, '07Leslie,
Sorry, my last posting was incomplete. Please advise how adding the pallitive care benefits broadens the scope and length of service and
avoids the slippery slopes. I don't understand the difference. Thanks!
Aug 20, '07Thank you for the link I shall have a read when I am home from another day in Hospice.
Blessings to you all.
Aug 20, '07I am wondering the same thing: How is “palliative care” reimbursed?
“Hospice” is a package deal; it includes, MD, Nursing (including CNA’s), SW, Bereavement (usually some sort of Chaplain) and a Volunteer dept. It is loaded (some might say overloaded) with services and required personnel. Lots of patients do not need or want all that hospice offers, so stripping services down to only what patient/families may want/need would, theoretically, be cheaper.
Then of course hospice has to contend with the bugaboo of being a program for the “terminally ill.” Some terminally ill people cannot face up to that and prefer a different program that enables their denial. All of which points to a need for a “palliative care” program… but how is it billed? Like Home Health? As “Home Health?” For individual visits?