Hospice

caliotter3 · Jun 24, 2011

I had a hospice patient for one shift who basically was a little old man on his way, nothing more. I don't believe that elderly people waiting to pass from natural causes meet the hospice concept as I know it. If so, then all of your LTC facilities should be called hospices instead and all the residents should get hospice care. JMO

Home Health Columnist / Guide · Jun 24, 2011

my experience: hospice underutilized rather than overutilized. hospice focuses on providing comfort and improving quality of life.

anyone with a life limiting illness with about 6 months life expectancy can benefit from hospice symptom management expertise along with counciling re anticipatory grieving + end of life issues patients and families face.

bereavment support to family members for one year after loved one passes helpful to prevent depression and facilitate grieving.

before i die: what is hospice?

what is hospice and palliative care? - the national hospice and

TheMoonisMyLantern, ADN, LPN, RN · Jun 24, 2011

In my opinion Hospice is not started early enough. The general guidelines for hospice is a diagnosis that bears a prognosis of 6 months or less to live with symptoms of decline. Dementia is tricky because we all know that that little 90 year old could live another day or live another 5 years so of course the 6 months or less rule is debatable depending on the circumstances as long as there are symptoms of decline (decreased appetite, mobility, pain, agitation, shortness of breath, ADL's, VS changes, etc. depending on the diagnosis).

The truth is that multiple studies show that the sooner one is started on hospice the better controlled pain and discomfort are controlled at the time of death. People think that Hospice is only for those that are actively dying and that simply isn't the case as we're seeing more and more people who remain on Hospice for a year or even more before finally passing away.

Remember, end of life care isn't about sedating or overmedicating or speeding up the dying process it's about making the patient comfortable. Frankly, no one is going to be able to restore that 90 year old man to his former glory, making him less miserable is all we can do.

summerrose_10 · Jun 24, 2011

to the OP if you were that pt. what would you want ??? Just curious, I got my BC in hospice/palliative care and that is where my focus is. However, I'm curious if you were the patient, what would you want.?

Anna Flaxis, BSN, RN · Jun 24, 2011

I agree, hospice is underutilized more so than abused! I think we live in a society that places too much emphasis on fighting death rather than embracing it as the natural process that it is. If I were a LOL agitated due to my advanced dementia, I would want that addressed. An agitated person is NOT a happy person. An agitated person is a scared, angry, frustrated, lonely person. The risks of sedation, in my opinion, are far outweighed by the benefits of feeling safe and calm. When I am that LOL, bring on the benzos!!!

NotFlo · Jun 24, 2011

One of the local hospice agencies in my area has a special dementia program. I am not exactly sure of what qualifies a person for this service except they have to have had a certain amount of decline over various areas over a certain amount of time. I have seen the extra care and attention (volunteer visits, private aide 5 x per week, nurse several times per week, etc.) be really helpful for many of the dementia patients enrolled in my facility. I would sign a loved one up that qualified for their services in a heart beat.

HollyHobby · Jun 24, 2011

I cannot think of a time when I saw a patient referred to hospice too soon.

I cannot count the times when I've seen patients referred to hospice too late.

As an ICU nurse, I define my career as "torturing people to death". This is what I do: I torture people to death. Eighty, ninety, freaking one hundred years old: I torture them all. They suffer and suffer. This is how I earn my pay.

It's shameful. But this is what the family wants. They want me to torture their "loved" one to death for their own sick and sad reasons. I have performed CPR on a 95 year old man who was so far gone with Alzheimer's Disease that he hadn't been out of bed for a decade. He didn't know who he was, much less who anyone else was. He was so contracted that his bony knees interfered with my CPR. Of course I felt his ribs break under my hands.

I've done many, many horrible and shameful things because the family insisted I "do everything". They say that to relieve their own guilt. Instead of them having to make a decision, I carry their guilt and hold the responsibility for their relative's death on my hands. When 90 year old grandpa dies, it's not THEIR fault. It's mine.

I hate myself for this. It's wrong. It's horrible and barbaric and wrong, but I continue to do it. What the family wants is what I have to do.

What does that say about me? I am a horrible person for doing these things. I am a criminal, in my mind. I make myself sick.

Vtachy1 · Jun 24, 2011

I cannot think of a time when I saw a patient referred to hospice too soon.
I cannot count the times when I've seen patients referred to hospice too late.
As an ICU nurse, I define my career as "torturing people to death". This is what I do: I torture people to death. Eighty, ninety, freaking one hundred years old: I torture them all. They suffer and suffer. This is how I earn my pay.
It's shameful. But this is what the family wants. They want me to torture their "loved" one to death for their own sick and sad reasons. I have performed CPR on a 95 year old man who was so far gone with Alzheimer's Disease that he hadn't been out of bed for a decade. He didn't know who he was, much less who anyone else was. He was so contracted that his bony knees interfered with my CPR. Of course I felt his ribs break under my hands.
I've done many, many horrible and shameful things because the family insisted I "do everything". They say that to relieve their own guilt. Instead of them having to make a decision, I carry their guilt and hold the responsibility for their relative's death on my hands. When 90 year old grandpa dies, it's not THEIR fault. It's mine.
I hate myself for this. It's wrong. It's horrible and barbaric and wrong, but I continue to do it. What the family wants is what I have to do.
What does that say about me? I am a horrible person for doing these things. I am a criminal, in my mind. I make myself sick.

This is precisely how I feel too, I was also an ICU nurse and did this exact thing for 15 years too long. I couldn't agree more.

Now I work for Hospice and feel so much better about what I do. Hospice is a way WAYY underused program. They have to be very very sick before we are allowed to admit a patient. To be admitted under the dementia diagnosis, They have to have significant weight loss in a short amount of time, can't talk, walk, or do anything basically they have to be on their way out of this world and transitioning into the next. I feel that we don't get these patients soon enough. I feel opposite of what original poster feels.

And I am AS PRO LIFE as a person could ever possibly be too. You won't find a more pro life person than me!

Hospice Nurse LPN, BSN, RN · Jun 24, 2011

What do you think about hospice? Do you think that MDs and nurse practioners abuse the concept of hospice, do you think that in some instance they push for hospice too soon? I always thought that it is extremely difficult to qualify for hospice and it really takes someone to be terminal before getting aproved for those types of services (since all the meds and treatments are covered) I have a patient who is 90 years old, full blown dementia, family took her off antidepressant since they believe the medication is too expensive (around 100 per month), she is also on haldol for agitation and temazepam for sleep, used to be able to bear partial weigth, lately she developed slight knee contracture and is now wheelchair bound, her apetite is ok, healthy heart, healthy kidney and liver, they say they want to make her comfortable,she is not in pain, just agitated due to dementia. Do they mean sedating her?

I see docs and NP's referring way too late. The concept of hospice is comfort care. When a pt is actively dying, IMHO, is way too late. What can the hospice team do for a pt who is actively dying upon admit? Not as much as we would like to. We do everything we can, but there is no real bonding between the family/pt unit and the staff. You can only get the symptoms under control as quick as you can and teach really, really fast. The earlier the referral, the better chance that the hospice team can address EOL issues w/ the pt and family. You stated that your pt was not in pain...are you sure? I'm thinking that a 90 y/o probably does have some pain issues (arthritis maybe?) and the agitation could be d/t pain. Hospice doesn't cover the cost of all meds and tx----just those that are r/t the admitting dx. In school, we are trained to save lives and it is sometimes difficult for us nurses to get out of that mind-set.

Even if a family requests hospice and the doc gives a referral, the pt won't be admitted to hospice if they aren't appropriate. Medicare/Medicaid have very strict guidelines concerning appropriateness. Sometimes pts are d/c from hospice because they either no longer meet the requirements (wt gain, no longer declining, etc.) Also some pts are on hospice longer than the six months because they continue to decline, just at a slower rate.

Hope this helps.

Whispera, MSN, RN · Jun 24, 2011

I can't tell you how many times I've seen patients arrive in hospice only to die within hours. Many doctors are resistant to referring to hospice. Remember, their focus is on curing. I think it's hard for many of them to accept that they can't do just one more thing to help their patients stay alive in hopes there might be a cure down the road.

I've seen many patients arrive in such physical and emotional pain that it's difficult to help them be comfortable. They are so overwhelmed by everything!

It would be so much better to get them into hospice sooner rather than later. Hospices are experts in comfort. Being in hospice doesn't mean the person will die. It just means they are likely to die within 6 months if their disease progresses at its own rate without intervention to cure it. I've seen hospice patients get better and go home!

Even if a person isn't in physical pain (and I'd bet money a 90 year old has pain!), agitation indicates emotional pain. Being off antidepression medications means the depression that had been treated is BACK! That's emotional pain. It's huge. I don't understand not prescribing the antidepression meds. Surely they can be considered part of comfort care.

I hope when my time comes, that there is a hospice available and my family takes me to it or brings it to me. I don't want to be in pain.

tewdles, RN · Jun 24, 2011

What do you think about hospice? Do you think that MDs and nurse practioners abuse the concept of hospice, do you think that in some instance they push for hospice too soon? I always thought that it is extremely difficult to qualify for hospice and it really takes someone to be terminal before getting aproved for those types of services (since all the meds and treatments are covered) I have a patient who is 90 years old, full blown dementia, family took her off antidepressant since they believe the medication is too expensive (around 100 per month), she is also on haldol for agitation and temazepam for sleep, used to be able to bear partial weigth, lately she developed slight knee contracture and is now wheelchair bound, her apetite is ok, healthy heart, healthy kidney and liver, they say they want to make her comfortable,she is not in pain, just agitated due to dementia. Do they mean sedating her?

I would recommend you do some research on hospice. That you look at the death and dying statistics of this country. I suggest you read about palliative care and what quality of life means to people who are at end of life...what it means to them and to those who love them. Consider who helps the family with bereavement after their loved one dies, who helps their children, their grandchildren.

Perhaps you could focus on the autonomy of patients at end of life, compare the autonomy of a patient suffering their last days in the hospital vs. those suffering their last days in their den or bedroom. Do you know who decides what happens when grampa is in the hospital? Who decides what happens to grampa when he is in hospice?

Are you aware of the average and median lengths of stay for hospice patients in the USA? This might be an interesting search for you.

Primarily I think that the OP, like too many others in the world of health care, are poorly informed about the vital importance of hospice and palliative care in the USA. And consequently, poorly informed about the important care that provided these patients and families at the second most life changing event in our lives...death.