New to Hospice - Continuous Care

leslie :-D · Nov 30, 2008

i have learned not to predict death...seriously.

we're all familiar with the s/s of imminent death, yet i've had too many pts that exhibited these s/s, only to bounce back for a bit.

i've also had pts that didn't exhibit any s/s and just died.

so whenever i'm feeling righteous and confident about the path a pt is taking, i immediately recall all those pts who proved me wrong.

enjoy the calm.

in the absence of distress/pain/suffering, it's really a beautiful process.

leslie

rngolfer53 · Dec 6, 2008

i have learned not to predict death...seriously.
we're all familiar with the s/s of imminent death, yet i've had too many pts that exhibited these s/s, only to bounce back for a bit.
i've also had pts that didn't exhibit any s/s and just died.
so whenever i'm feeling righteous and confident about the path a pt is taking, i immediately recall all those pts who proved me wrong.
enjoy the calm.
in the absence of distress/pain/suffering, it's really a beautiful process.
leslie

I'm with you. I hate being asked how long, etc. I've proven to myself that I have hardly a clue. When families ask--usually a few minutes after I tell them that I can't predict--I just suggest that if there are others who want to see the Pt while still alive, it would be a good idea to call them.

Anybody have approaches they use?

marachne · Dec 6, 2008

I'm with you. I hate being asked how long, etc. I've proven to myself that I have hardly a clue. When families ask--usually a few minutes after I tell them that I can't predict--I just suggest that if there are others who want to see the Pt while still alive, it would be a good idea to call them.
Anybody have approaches they use?

My favorite approach is to use a birth analogy -- I ask if they have had children. If they have, I ask them to think back to when they/their partner was pregnant, and how they had all kinds of visions about how the birth would go, and how it wound up being so different from what they imagined (including the timing).

I continue the metaphor through discussion of the "two great life passages" and how no matter what we think, none of us have control over these times, and that it becomes a matter of the spirit of that individual and who/whatever power there is out there that is beyond what we know (I'll say god if I know the person is religious in a way that that would be appropriate).

I've gotten a really good response to this -- putting things in already familiar terms I think helps them understand.

If they are asking specifically about "is it time to call person X to come?" I sometimes will ask what they think is important to person X -- if the pt is still conscious, I ask if it is important for them to be there when they can still interact, in which case I will encourage them come "sooner rather than later." If they are not conscious, I still might put it in terms of "well, if they come sooner, they are more likely to be able to say good-bye...

Really no hard and fast rules, b/c as we all know, all families are different and have different needs.

rngolfer53 · Dec 7, 2008

Great ideas. Thanks for your generosity in sharing them.

kaylee3 · Mar 2, 2009

Hi

Read your post---have been thinking of going into hospice. I am an LPN and was wondering what continuous care is all about? Is it one on one for 12 hours? Thanks.

kat7ap · Mar 3, 2009

Hi
Read your post---have been thinking of going into hospice. I am an LPN and was wondering what continuous care is all about? Is it one on one for 12 hours? Thanks.

Continuous care is one to one for your entire shift. I work 13 hour night shifts. We care for hospice pts who are actively dying and/or need pain/symptom management and pt/family teaching. It's all about comfort care and supporting the pt and family members. Some cases can be more complex, but for the most part it is basic nursing care with good assessment skills needed, and giving comfort meds such as morphine and ativan as needed. It does require being comfortable with the death and dying process. My cases are in private homes, nursing homes, and assisted living facilities.

rnboysmom · Mar 3, 2009

Very scary that you are describing continuous care hours for "hardly any symtoms or symptoms that are very easily controlled". CMS is very clear in the regs that continuous care is for short periods of crisis. Palmetto GBA describes continuous care coverage as follows in section 4.5.2.1 Coverage:

1. Continuous home care should be provieded only during a period of crisis as necessary to maintain the terminally ill individual at home

2. A period of crisis is defined as a period in which a patient requires predominantly nursing care to achieve palliation or management of acute medical symptoms.

Be careful to document that you are controlling acute symptoms that are out of control. Also, the continuous care benefit is not appropriate for the normal dying process.

kat7ap · Mar 3, 2009

Very scary that you are describing continuous care hours for "hardly any symtoms or symptoms that are very easily controlled". CMS is very clear in the regs that continuous care is for short periods of crisis. Palmetto GBA describes continuous care coverage as follows in section 4.5.2.1 Coverage:
1. Continuous home care should be provieded only during a period of crisis as necessary to maintain the terminally ill individual at home
2. A period of crisis is defined as a period in which a patient requires predominantly nursing care to achieve palliation or management of acute medical symptoms.
Be careful to document that you are controlling acute symptoms that are out of control. Also, the continuous care benefit is not appropriate for the normal dying process.

Well perhaps things are different where you are, but my hospice uses continuous care as well for pts who are imminent even though their s/s are easily under control but they are still having normal progression of dying such as decreased LOC or nonresponsiveness, apnea or increased temp. So you are saying that not every hospice pts death needs to be attended by hospice continuous care? Maybe I worded my original post wrong. We do use CC for short periods of crisis - either the pt expires or the problem has been managed and they come off. I am not the one who decides the approriateness of CC, that is the case manager's job.

rnboysmom · Mar 3, 2009

What I am saying is that "billable" continuous care has specific guidelines under regional and federal guidelines. NHPCO lists an excellent set of examples in their Hospice Operations Manual that are viable reasons for continuous care,including the following: Severe pain,acute respiratory distress, acute nausea/vomiting, seizures,hemorrhage,severe agitation,confusion with safety threat and suicidal ideations or related actions..... As you can see, all of these are quite different from the normal dying process. And no, the normal dying process is not a need for continuous care. The symptoms that you describe are normal dying process symptoms that are easily managed (decreased LOC, non-responsiveness, temp, apnea, etc.) and are not reasons for initiating continouous care unless they are causing the patient distress or are not easily managed by routine meds and education. Some hospice companies have care teams that do sit at bedside with their dying patients; we sit at many bedsides of dying patients and provide support through the process, but assisting the patient through the normal dying process is not continuous care that is considered "billable" under the hospice benefit. Sitting at bedside is a wonderful benefit that a hospice offers patients, but if a company is billing at the higher level of care--the continuous care level of care that requires an acute crisis and acute symptom management, I take issue with that, as I am sure do others. We all have to be stewards of the benefit, or it will dissappear. You are correct that the RN case manager determines the level of care, but if your company is BILLING for the continuous care level of care for sitting at bedside during the normal dying process, what they are doing is unethical at best.

kat7ap · Mar 4, 2009

Well I'm really not going to argue with you, but where I live there are over 100 different hospice companies that routinely provide continuous care for pts that are actively dying even those with "normal death process". I do not think my hospice company is doing anything unethical. They are one of the largest in the area and have offices in several other states. If what they were doing was "wrong" it would be realized, I'm sure of that. Then again I don't know very much about what is and what is not "billable", I just go where I am assigned. There have only been a couple cases where I felt the pt was not really approriate for CC, and at that point they were normally d/c'd the next day (we have to give 24 hr notice).

rnboysmom · Mar 4, 2009

at,

My intent was not to gain an argument, but rather to explain the benefit. My apology is sincere. I left a better message on your profile page.