My question to you hospice specialists, is that is hospice nurse and hospice case manager different? My company is contracted to clients in home or facility (SNF, nx home, etc) and requires me to visit them. I accepted this position because I want to learn case management, not more bedside nursing or direct patient care, I already have that experience, and that is not my intention going into this. I want this to become a stepping stone experience to further my opportunity in case management, and if all I will be doing is more bedside nursing tasks, then that is not what I am looking for. What advices do you have for me? Thank you.

How are other on call nurses being compensated? How many hours are you typically working a week/night? Are you doing only emergency admissions, or is management scheduling after hours admissions to accommodate family members that want to meet after 5 pm because they worked that day? Are you helping with regular visits that cm's couldn't get to that day? Do you take PRN visits that come in after 4 pm so the cm doesn't have to work late? Sorry this is so long! 

Tl/Dr: on call weeknight RNs, how are you compensated and on average how many hours are you actually working?

Thank you so much for any insight!!

Hydromorphone ER 12 mg q12h

Hydromorphone 2 mg q3h PRN

Diazepam 10 mg × 2 at night for muscle pain/spasm

He's enrolled in a palliative program, not hospice.
Despite the regimen, he's having increasing spasms that interfere with sleep and daily comfort.
His PCP is hesitant to manage the narcotics due to the complexity of his condition and the regulatory environment. Any advice?

How do you convince those that never see the patients that increasing the numbers to serve more members of the community, and failing to serve is actually making it only about numbers? 

We are the only hospice in the area. We have no competition. If patients are close to death already, they are in the hospital on comfort care. If they are short stay, but going home with family and just need a lot of attention... we don't have the resources. 

It seems they only make decisions based on data but do not actually collect any meaningful data! Wait until the next surveys come out or the next audit to get dinged again? It is crazy making for those of us on the ground who care!

We have a hospice house, but staffing issues often limit getting all the beds filled. We don't have the staffing to regularly do continuous home care.

Now we are regularly over 120, and sometimes at 130. There can be a lot more call ins after 5pm and before 830am, with families or patients demanding visits. The trend I have noticed, is they have called in about the issue for 2-3 days already. And though each triage nurse might have temporarily helped the situation, they reach a point where they just want a nurse to come see. 

It is the worst around school holidays and vacation times. Management lets as many nurses off as they can, then others are sick. So we might be super stretched thin and more phone calls are made than visits.

My shift is 5p-9a. We have a phone service for triaging the simple stuff, but more and more visits are being handed off to me at 5pm or being demanded by family shortly after I start. I have been trying to find information on what number of hours regularly worked in a shift indicates it is no longer truly an on-call shift. 

I have looked at some labor sites. We are paid above minimum wage (of course). We get a rate for the first 8 hours that is about 72% of our regular hourly rate. Then 4 hours of 1.5x that rate. Then 4 hours of 2x that rate. So that complies with California state law.

Just haven't been able to find anything that says, if you work 8, 10, or 12 hours of that 16 hour shift regularly, it should not be considered an on-call shift and the agency needs to move to creating two 8 hour shifts to cover those 16 hours. 

One hospice I worked at just had one 8 hour shift in the evening that ended around midnight. And another staff member who came on at midnight for an 8 hour shift that lasted until the office opened. 

I do not know how the other two nurses working this shift feel about it. They are aware that I am asking questions, but not sure what they actually think. 

It would be legitimate if we were no longer 'on call' to ask the nurse working the shift to do 1-2 visits. It is hard to plan though, as we already have trouble doing things that are passed on by the day shift, as there are always issues coming up that are urgent or emergent (like falls with serious injury, etc.)

Anyone familiar with this kind of distinction? When X number of hours are regularly worked it cannot be called "On-call". Or is it just employees in the roll insisting on a change?

I am curious if mainland hospices are using suction in the home as a standard of care for hospice pts with dysphagia. I have been a hospice nurse for 20 years and my understanding is that use of suction was more than the exception and not the rule for best practice in managing dysphagia. The organization I work for is using suction on the regular. It is a standard order. Is this the norm in your hospice and I have just missed the boat in my years of training? I find it a burden to pt and family, an infection risk, and potential for causing more harm than good. Thoughts please! Mahalo! Melissa 

My first job as a new grad was in the SICU, and back then I probably would have told you the same thing. I imagined hospice to be a depressing and hopeless place to work, and I never thought it could be gratifying or rewarding. After all, how could it be when all of your patients end up passing away no matter what you do?

The patient deaths I experienced while working in critical care were completely traumatic for me. I'll never forget the sickening cracks I felt the first time I performed chest compressions on a patient. I can't tell you how many patients' last words were "I don't want to die." It felt like I was going toe to toe with death himself, and I didn't stand a chance. I was stressed, depressed, and burnt out. 

My entire outlook changed with a single patient and her family. She was older, intubated, and on CRRT, so I had her as a 1:1 for all of my shifts that week. She had 2 adult daughters that were so, so close to her. I sat with them through the night shift, taking care of their mom and getting to know them. We laughed together, we cried together. By the end of that week, I considered them dear friends.

The unit I was on was amazing. We had an excellent team, and we really tried every single thing we could to help that patient. We fought for her, and we fought hard, but by the end of that week we could see that it was a wasted effort. Our patient was dying. Mom was dying, and I had to come to grips with that. Then, I had to break the news to my dear friends.

There were so many tears shed that night. I held their hands, tears running down all of our faces, while the doctor explained what a DNR is to them; when he explained what terminal extubation means; when they finally signed the papers that meant the end of mom's life. 

I was with them when they held her hands, saying their final goodbyes and singing Amazing Grace while mom took her last breath. I fell to the floor with them, doing my best to hold them together while their hearts shattered.

I fought against the hospital administration that tried to rush mom's body out of the room instead of allowing time for the last family member to get there and say goodbye. I made sure that she could be picked up by a close family friend and funeral director instead of having to spend time in the cold, clinical hospital morgue. 

That patient was intubated when she got to my unit, so she'd never actually spoken a word to me, but she became one of the most important patients I've ever had. Looking back, her death was the most profound experience of my hospital career.

Losing her really did break my heart, but I am so eternally grateful for it. I am so thankful that I was there to hold her daughters while they grieved for her. I am so thankful that her last moments were Amazing Grace instead of broken ribs. I am so thankful that she was my patient when she died.

Very soon after that, I left the hospital and went to work for a home health hospice company. I lost every patient I had, and I am still so thankful for it. I'm not glad that they were dying, but they were going to be dying anyway so I am so glad that I was able to be there for it. Their families were not alone. I made sure they were comfortable, I eased their pain, and I protected their dignity. I held hands. I shed and wiped tears. There were times I stayed with them all night just to be sure they weren't alone in their last moments.

It was sometimes completely exhausting and emotionally draining, but I cannot begin to express the relief I felt from the burden of trying to save a patient that death had already claimed for his own. I didn't have to be a nurse anymore. I got to be a nurse. 

We are a new hospice agency (2 years) in a rural area in Colorado and are having some growing pains. Currently, our clinical supervisor (RN) and our lead RN are taking all of the call (week on/week off). They are the only FT RNs. We have one FT LPN who lives locally, and one PT RN, who lives an hour away and doesn't want to take call (semi-retired). Finding nurses who want to do hospice/take call has been a struggle, and why we hired a PT RN and an LPN (can't pronounce deaths). We discussed an on-call service, but due to the cost, it has been tabled until we have more growth. Our census is currently 20.

I think the main issue is not the amount of after-hour calls or visits (although that can be a lot on some nights), it's that the 2 call nurses need to have their phones on them at all times, don't sleep well (waiting for call), need to drive separately from their families when they go to dinner in case they get a call, and because we are in a rural area, they and their families are very limited on where they can go so they don't end up in or crossing or ending up in an area that does not receive cell service. Even if others are taking the calls and triaging, they still need to be available and ready to make an urgent or death visit.

Both of our call nurses are beyond burned out. Has anyone been in a similar situation and have any creative solutions?

In Colorado, an RN can pronounce hospice deaths after training. What if an LPN attends a death visit, reports vital sign findings to RN on call (via phone), and the RN pronounces this way? Has anyone heard of this? 

Thank you in advance!

**Bonus points for links (or general direction) to law or Colorado BON scope of practice that supports a legal, creative solution within scope ?

My question is...  if these are not being used for HD any longer, and we are giving meds at least every 4 hours ATC and sometimes more often, has anyone used a Permcath on a regular basis during end-of-life care in an acute setting. 

There are times where I work 12 or more hours of the shift, and last night was one of them. These nights have gotten more rare in the last 6 months, but when they come they come in sets of 2 or 3 nights in a row. Argh! 

This Summer, with a higher census than usual, and staff encouraged to take all the vacation they need for a happy life, so much more falls on to night shift. Of course day shift and management needs to stay a little delusional to avoid upsetting the apple cart. All have to believe that their caseload will be taken care of if they are off sick or on vacation. Even if all but a couple nurses are left after all the sick calls?!? Fridays in the Summer? Ack.

It doesn't help that patients are coming on when they are near death's door, it is a very intense teaching EOL and symptom management slope... and de Nile, de Nile. My 85 year old sister who is dying can't have morphine... people die after taking morphine.... but we will agree to Dilaudid. What?!?! So narcotic naive patient can go straight to Dilauid? 

So she can call out in pain and suffer for 6 plus hours with morphine on hand, but need to wait for Dilaudid. Cuz that will be better? And will hospice be to blame that it takes over 6 hours for the pharmacy benefit manager to process this order? Who knows. I am not there to do the daytime teaching/coaching.... so after being there for 90 minutes in the middle of the night and getting her comfortable and updating the POA, I am going to have to do it again tonight? Hells to the no. If I get a call again tonight at 3am, then I am going to call the POA before I drive 20 miles and ask if the goal of care if actually comfort. If not, no drive. If it is? Well, I guess I will drive it again. And do it all again. And then the sister will come in and blow it all up the next day. People with money and no sense annoy the crap out of me.

Okay

1 for frustrated

2 for irritated

3 for sleep deprived

I wonder if this is ethical.  I think this is experimenting on patients.  Also, no literature about side effects is given or ingredient list.   I wrote to my BON and they replied , in part, with this.... We are unable to advise on setting specific or client/patient specific practice questions

I was hoping the BON would give me something I could go to my boss with.  What would you do?

Hospice nurses- would you mind telling me what a general day would look like for you? How many homes you would go to? How is your job duties different when you are just checking in on a patient vs a patient actively dying? If someone is actively dying are you staying there or just called once they have passed if they are comfortable? It's such a new area of nursing but one I'm interested in so I'd love to be able to visualize how a shift would go. It would most likely be a PRN home position. 

I was then given the option to remain 7 on/7 off and if I want to help on the off week until they are able to find someone, I can or I can move to a weekend only call (Fri night through Mon morning) and the case managers and clinical manager would cover M-Thur. call.  Though it was left up to me, the preference seemed to be for me to take the every weekend call so the case managers can get a break from working basically every day. For the record, working every weekend is not a big deal to me.

Census is in the 30's. There is no triage just an answering service. Position is salaried plus mileage & cell phone allowance. I would be paid additional if I worked any hours over my agreed schedule. At this point I am/would be the only true on call nurse, I am told there would be no pressure at all to pick up additional time as they want to be respectful of my time off and my employment agreement. 

The 2 case managers have been at the company less than a year, the clinical manager less than a month. There is no Director, the one they had resigned in late 2023 less than 6 months into the position, no replacement has yet been found. The current clinical manager is the 3rd one in less than a year.  They had 2 social workers but one left and the other transferred to another office, the 3rd one has been with the company about 90 days. The hiring person was upfront about the turnover and indicated it was more of people not wanting to remain working in hospice than issues w/the company. The company is not a locally owned and does have offices in other parts of my state as well as adjoining states. It is medicare/private pay but will soon accept medicaid patients. 

I don't know why I am hesitant to move forward now.. I am not a new nurse, but am new to hospice. I worked hospice briefly about 10 yrs ago for a small agency that ended up going out of business but have worked home health, the hospital and clinics.

It would be nice to have the flexibility that comes w/the position but I'm just not sure now. I need and have to work but I have another part time offer I could accept and find something in addition to that if needed. I don't want to be shortsighted so any advice is much appreciated.

I finally decided I'd review, shell out the $415 and take the test early next year.

I am more of a hands-on, visual nurse and retain information pretty well. That is why I'd rather do practice tests than read a book or flip through index cards. 

Anyone recommend a website for CHPN online practice tests as a review tool?

Thanks in advance!

 The position was to be Sat/Sun only and the offer letter stated "weekend on call" but no specific hours. I confirmed with HR and the Administrator it was Sat/Sun only (48 hrs total).

My first day I was told by the Administrator the position hours were "adjusted by corporate leadership" and weekend only was to be Fri 5pm-Mon 8 a.m. so if I wanted to work only weekends that would be the schedule. I was surprised but agreed. There is no triage and no back up on the weekends other than the Administrator for questions. Mileage was to be from my home to patients houses and back since it's on call, that also has changed and mileage is now as though I am a case manager - no mileage to first patients house but mileage kicks in if the patient lives more than 15 miles (which they all do).

I still do not have a nursing bag or badge and have to call the Administrator if I need to make a visit to schedule it in HCHB as IT has yet to set up my access correctly (and yes, I've made multiple attempts to get it corrected and continue to be told "they are working on it")

Today I was asked to "tack on" another night "or two" of call during the week though it would be paid at a lesser rate since the weekend position is salaried. Though it was presented as a request I get the feeling it will soon be required. There are 2 FT Case Managers, the Administrator, who is an RN and a FT Clinical Manager (also an RN) and a FT LPN. The census is 14. The CM do not do Admissions unless the Clinical Manager or Administrator is busy as the company prefers for the Admin or Clinical Manager to do the visits. Since I started a few months ago there have been 3 admissions so Admissions are not an everyday/every week occurrence. 

 I understand CM work M-F and have IDG every 2 weeks but IDG is via phone and the CM they are literally working less than 5 hours a the days they do work and are not seeing patients at all several days a week. When I am on call I am triage and going out for visits the entire weekend (5p Fri to 8a Mon). Call volume is higher on weekends for various reasons.

I feel taking on an additional 2 nights of call a week and at a lower rate is asking too much. I don't mind picking up extra call time to time to help out but I feel with the census as low as it is, the CM not working a true 40 hr week asking me to pick up 1-2 additional nights and at a lesser rate, is taking advantage - am I wrong?