Is Continuous Care in a client's home history??

[RKMARK]

Hello to those of us who are called into Hospice Nursing. I have been an RN for so long, my first job was keeping Flo's candles lit. In those years, I have practiced in Med-Surg, ICU,CCU, ER and community nursing before finding my real love........Hospice Care. Having began my Hospice career seven years ago by working "continuous care" cases in the client's home, I recognized the extraordinary journey that began by entering a home of individuals usually unknown to me previously, and being honored with the trust they bestowed in me to walk beside them in such a difficult time. The opportunity to apply the skills I acquired in providing comfort, pain management and emotional support has always been my view of the essence of nursing. It has always been my philosophy that it is ones ultimate dignity to die in ones own bed, surrounded by the familar faces and possessions that completed their life.

However, after a two year hiatus from Hospice practice, my personal observation is that this basic aspect of historical Hospice care has been lost. It seems that the two Hospice organizations I have been associated with here in Arkansas have all but abandoned respecting the patients wish to remain at home with professional care to ease the death process. Instead, the overiding practice of filling up the beds in the in-patient unit appears paramount. If one's wishes are to die at home, the current practice seems to be providing (at best) sporadic care from a CNA (who, for the record, I have the utmost respect for) or leaving the patient and family to their own devices with no resources other than a list of telephone numbers to be called after the event.

I am curious if this is isolated to my particular area, or if other Hospice professionals have encountered similar practices? I fear we may be abandoning a very basic tenent of our promised commitment to our patients in exchange for more lucrative (and selfish) motives. Any comparisions or opinions from my colleagues around the country would be greatly appreciated. All my best to each of you. Robert

[tewdles, RN]

Hello to those of us who are called into Hospice Nursing. I have been an RN for so long, my first job was keeping Flo's candles lit. In those years, I have practiced in Med-Surg, ICU,CCU, ER and community nursing before finding my real love........Hospice Care. Having began my Hospice career seven years ago by working "continuous care" cases in the client's home, I recognized the extraordinary journey that began by entering a home of individuals usually unknown to me previously, and being honored with the trust they bestowed in me to walk beside them in such a difficult time. The opportunity to apply the skills I acquired in providing comfort, pain management and emotional support has always been my view of the essence of nursing. It has always been my philosophy that it is ones ultimate dignity to die in ones own bed, surrounded by the familar faces and possessions that completed their life.

However, after a two year hiatus from Hospice practice, my personal observation is that this basic aspect of historical Hospice care has been lost. It seems that the two Hospice organizations I have been associated with here in Arkansas have all but abandoned respecting the patients wish to remain at home with professional care to ease the death process. Instead, the overiding practice of filling up the beds in the in-patient unit appears paramount. If one's wishes are to die at home, the current practice seems to be providing (at best) sporadic care from a CNA (who, for the record, I have the utmost respect for) or leaving the patient and family to their own devices with no resources other than a list of telephone numbers to be called after the event.

I am curious if this is isolated to my particular area, or if other Hospice professionals have encountered similar practices? I fear we may be abandoning a very basic tenent of our promised commitment to our patients in exchange for more lucrative (and selfish) motives. Any comparisions or opinions from my colleagues around the country would be greatly appreciated. All my best to each of you. Robert

I agree that continuous care is not offered or accomplished as often as it might be. And, yes, I do agree that it is likely related to the financial concern...although, NFP agencies are likely not selfish about this as much as they are attempting to make their dollars stretch further than freq use of continuous care would allow. I work for an agency which also has a residential and GIP facility. We rarely transfer folks there for the dying process, reserving those beds for persons with acute symptom management issues or those desiring a SNF bed. Our philosophy is to empower the family to the greatest level of autonomy in caring for their loved one. When the patient is actively dying we increase our visit frequency and offer continuous care if the family appears to need additional help...but the majority refuse, feeling that they can handle it. I find that most do just fine...and the survivors have a significant sense of peace and accomplishment about what they were able to provide.

Having said that, I do know of another hospice agency in my general area which uses continuous care more often. The case nurses manage more than 12 patients routinely and they generally are not able to visit more than once weekly. They have a continuous care team which is used frequently. My suspician is that if the case managers were able to visit more often in the days/weeks leading up to the death, they may be able to educate the family to the point that the continuous care might not be necessary. Just a thought.

[RKMARK]

Thank you for your response, and your points are well taken. I suppose that the reimbursement structure has changed greatly in the past two years........and no hospice can keep their doors open if they go broke. Thanks for your prespective.