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Palliative Care + Hospice = A+

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In this article the author explores the differences and similarities between hospice and palliative care and how they work together.

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Palliative Care + Hospice = A+

November is National Palliative Care and Hospice Month

I scrolled down through the EMR and found what I was looking for: Palliative Care Consult. As a hospice nurse, we often get referrals from Palliative Care and their consult is a great place to start reading to get a picture of where this patient has been and what their current situation is. As I read, I discovered the 72 year old patient had extensive lung cancer and had been treated with radiation. During treatment, he began to have severe bone pain as the disease progressed. His oncologist called in Palliative Care to assess the current situation and to begin discussions with the patient about possibly transitioning into hospice care.

After reading through the consult, I felt more comfortable about beginning a conversation with the family, knowing that the door to end of life conversation was already open and that hospice was not a completely foreign term to them. I gathered up the referral, the patient's history and physical, and general information about our particular hospice agency before I headed down the hall and knocked on the door, ready to do the Hospice Evaluation to determine if the patient was ready for and qualified for hospice care.

After knocking, I heard a soft, "Come in," on the other side and pushed the door on open. In the small hospital room I saw the patient in the bed, his white hair blending into the pillow, oxygen in place, hands on either side of the tucked in sheet, palm down, as if holding the bed in place by the force of his will. He smiled, a kindly smile and said a weak hello. Beside him sat his wife, eyes lined with worry and circled with dark shadows that betrayed long hours of vigil. I introduced myself as the hospice nurse and saw his wife's mouth make a small "oh" as she exhaled long and deep. After pulling up a chair, I sat down and started by asking him how he was feeling and how the pain was at this time. After we got to know each other a bit, I began to gently explain what hospice is and does.

While hospice partners with palliative care, the two serve distinct and different purposes in the health care arena. Palliative care joins the patient's health care team when there is a need for symptom management during the treatment phase of long term illness. They help respond to a variety of troubling symptoms including pain. They are experts in identifying and foreseeing potential problems that complicate the patient's ability to continue to find enjoyment in life.

Palliative care also plays a strong role is helping families begin discussions about Advance Care Directives. Because of their specialized training, they have the ability to approach the topic of the patient's end of life wishes with sensitivity and finesse.

Hospice care comes into the picture when the physician team feels that there is a shortened life expectancy of six months or less. While this time frame is difficult to pinpoint, in practical terms it can mean that the patient has extensive disease that continues to advance with limited therapeutic value to be found in any available treatment modalities. Whether it is cancer, or end stage lung disease, or end stage heart disease or end stage renal disease, or some other life-limiting condition, the hospice team's role begins when all options are weighed and in the balance the potential success of treatment is overcome by the potential difficulties of complications.

So why would you pick hospice instead of palliative care? Palliative care is office and hospital based and still in the realm of focusing on potential treatments and possible rehab. It is centered on alleviating symptoms while the physician, patient and/or the family are continuing to pursue live-extending treatments.

Hospice, on the other hand, is defined by the expected shorter term lifespan of six months or less. Clearly, many patients live longer than the six months since none of us has the ability to fully forecast disease progression, but it is the most educated assessment possible.

By Medicare guidelines, hospice patients must meet the six month life expectancy estimate and also be ready to no longer continue in the treatment phase of disease management. In other words, no more chemo, radiation or interventional testing. "Yes, but I have heard of patients in hospice who continue to get blood transfusions or other care." So true. On a case by case basis, hospice does, at times, administer transfusions -for comfort. Or schedule a paracentesis, or do some palliative radiation for pain management. But in a general sense, when a patient enters hospice, they are weary of the treatment phase and mostly want to be at home to receive care from the team that includes a nurse, nurses' aides, spiritual care and social workers.

Some hospices have a Hospice House and all have agreements with long term care facilities where their patients can go for more complicated symptom management or for respite care when family members becomes exhausted. Roughly 75% of hospice patients receive their care exclusively at home-whatever that "home" definition is-but from time to time it is important that they be transported to a more specialized facility when home-based care can no longer meet their symptom management needs related to pain, dyspnea, agitation, restlessness, etc.

As we finished our conversation, I could see the patient and his wife relax a bit. While hospice is never a welcomed development in the course of treatment, it can bring some peace and resolution to the turmoil of months of difficult decisions. I shook hands with the patient and his wife, and we made an appointment to meet the next day to do the hospice admission at their home. With a smile and a wave, I pulled the door closed behind me.

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Joy has been a nurse for 35 years, practicing in a variety of settings. Currently, she is a Faith Community Nurse. She enjoys her grandchildren, cooking for crowds and taking long walks.

14 Likes, 4 Followers, 81 Articles, 144,544 Visitors, and 358 Posts.

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Really enjoyed this article. Maybe I should try hospice nursing - that thought crossed mind and I have never considered hospice before.

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Really enjoyed this article. Maybe I should try hospice nursing - that thought crossed mind and I have never considered hospice before.

You might consider reading some of the other articles I have written that talk about "A Day in the Life of a Hospice Nurse" or other hospice-related topics. They might give you a little more insight. Good luck! Joy

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I care for end stage renal disease patients who are all considered palliative care even the very young ones. Palliative care is not about dying, its about living each day as much as you can.

I talk very frequently and openly to pts about death and dying and what they can probably expect if they choose to withdraw from care. I try to let them know that it is very important for them to let their families know what their wishes are and I speak to the families often also. (With pts permission of course).

Great article. Thanks for sharing.

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Thank you for sharing your experience.

In high school, I volunteered for my local hospice center and learned what an important role hospice care plays in a community.

I am now in an RN program in Florida and hope to graduate in 2018.

I have a question about palliative care that someone may be able to answer on this forum. I understand the difference between hospice care and palliative care, but I am curious about palliative care theory and how it differs from holistic nursing care.

From my understanding, palliative care experts are able to recognize and help care for symptoms associated with serious health problems. In an ideal world, I would hope that nurses in all specialties would be able to be sensitive to these needs. Can you offer any history or insight on this matter?

Thanks!

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Thanks for writing this article. It helped shed some light on a situation which I'm still trying to process.

Recently, I experienced a situation that I'm not completely comfortable with regarding End of Life Care. I work long term and rehabilitation in a skilled nursing facility. I'm new to nursing so I'm not exactly sure of how things operate in other environments.

We had a patient with multiple co morbidities- acute CHF, Afib, Asthma, and HTN but nothing immediately terminal. She came to our facility with a hip Fx and a fair chance of recovery. Initially she made good progress with rehab but later she began to decline and developed a lingering cough and SOB. Eventually I got Doc to order a chest xray and sent her out to the hospital with pneumonia.

A few days after her return, she developed S/S of a DVT. So I got Doc to order an Ultrasound to confirm. I let her know what she could expect after receiving the results e.g. treatment, meds, etc. At that point she indicated she no longer want to continue living. I went to talk to Doc about the results from the Ultrasound, get an Rx for Xarelto, and happen to mention her desire to stop living.

He stated that it was, a good time to have a discussion about palliative care with the Pt and her family”. I asked him when he would like to schedule a talk when I was taking the order. He stated, whenever you like, we can't keep these people alive forever”, otherwise indicating to me it was something he wasn't going to do.

I spoke with the Pt and her family. Things were very somber and copacetic. I took an order to D/C her meds and placed an order for Roxanol, Atropine, Ativan, O2 and comfort measures e.g. ice chips, Chap Stick, oral care. She passed a few weeks later on my shift, peacefully and on her own terms.

Obviously I wasn't the only nurse providing care for the patient but it seems like a large portion on the responsibility was carried by me, a very new nurse. It was a bit emotionally taxing because I became the 'go to person' for the Pt and family. We don't have a Palliative Care team and our Social Services department didn't want to play. Am I missing something or is this how things are supposed to go down?

Since this situation transpired, I've taking the initiative to research and develop a palliative care facility protocol solely under the encouragement of our Doc. I would appreciate any positive input with regards to this situation. I feel like I'm a bit out of my depth and just operating on just a wing and prayer.

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Thanks for writing this article. It helped shed some light on a situation which I'm still trying to process.

Recently, I experienced a situation that I'm not completely comfortable with regarding End of Life Care. I work long term and rehabilitation in a skilled nursing facility. I'm new to nursing so I'm not exactly sure of how things operate in other environments.

We had a patient with multiple co morbidities- acute CHF, Afib, Asthma, and HTN but nothing immediately terminal. She came to our facility with a hip Fx and a fair chance of recovery. Initially she made good progress with rehab but later she began to decline and developed a lingering cough and SOB. Eventually I got Doc to order a chest xray and sent her out to the hospital with pneumonia.

A few days after her return, she developed S/S of a DVT. So I got Doc to order an Ultrasound to confirm. I let her know what she could expect after receiving the results e.g. treatment, meds, etc. At that point she indicated she no longer want to continue living. I went to talk to Doc about the results from the Ultrasound, get an Rx for Xarelto, and happen to mention her desire to stop living.

He stated that it was, a good time to have a discussion about palliative care with the Pt and her family”. I asked him when he would like to schedule a talk when I was taking the order. He stated, whenever you like, we can't keep these people alive forever”, otherwise indicating to me it was something he wasn't going to do.

I spoke with the Pt and her family. Things were very somber and copacetic. I took an order to D/C her meds and placed an order for Roxanol, Atropine, Ativan, O2 and comfort measures e.g. ice chips, Chap Stick, oral care. She passed a few weeks later on my shift, peacefully and on her own terms.

Obviously I wasn't the only nurse providing care for the patient but it seems like a large portion on the responsibility was carried by me, a very new nurse. It was a bit emotionally taxing because I became the 'go to person' for the Pt and family. We don't have a Palliative Care team and our Social Services department didn't want to play. Am I missing something or is this how things are supposed to go down?

Since this situation transpired, I've taking the initiative to research and develop a palliative care facility protocol solely under the encouragement of our Doc. I would appreciate any positive input with regards to this situation. I feel like I'm a bit out of my depth and just operating on just a wing and prayer.

It would have been part of the doctor's responsibility to have the initial discussion with the family. It would have been nice for you to be present so that you could address questions or concerns related to the discussion. Sometimes after the initial discussion, the physician will write for a hospice evaluation, if that is appropriate. Hospice can then continue to provide appropriate information and support. I hope this helps.

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I just completed a End-of-life care college class with my nursing school. I enjoyed the class very much. We were taught how to be compassionate and empathetic to the patient and family. At the end of the class we had a simulation day where we were put into different scenarios and had to use what we learned from the class to communicate effectively to patients and their families. I enjoyed reading your article as well.

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I just completed a End-of-life care college class with my nursing school. I enjoyed the class very much. We were taught how to be compassionate and empathetic to the patient and family. At the end of the class we had a simulation day where we were put into different scenarios and had to use what we learned from the class to communicate effectively to patients and their families. I enjoyed reading your article as well.

Wow, that sounds like a great class and wonderful preparation. I'm so glad you were able to be a part of it. No matter what field of nursing you end up choosing, those lessons will have long term application. The best to you! Joy

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Hi cyc0sys, I can offer you my experiences as a hospice nurse for 5.5 years and prior to that ICU. In the medical profession, we all want to treat, fix and cure. I am in complete agreement with that as long as several things are met; the patient, family if the patient does not have capacity, understand all options and choose a course of treatment based on information of ALL choices. You talk about your patient, in long term care, with multiple comorbidies, not sure how old the patient is but is sounds like older, who came to your facility to rehab a recent hip fx, developed DVT and verbalized she didn't want to continue living. That is the gift this patient gave to you and to her family;she made her wishes known, she no longer wanted to continue with the treatments and wanted to experience a peaceful death. I say this is a gift because so often, when my team and I are taking care of our hospice patients, the patient has not made their wishes for end of life known and this presents a difficult decision for some families. Because this patient was able to verbalize her wish, we are now able to provide the kind of care she wants. The main article talked about the difference between palliative care and hospice care. The goal of hospice is to provide the best quality of life everyday for how ever many days someone has to live and support the patient and family with a peaceful death. The quality of life peace is supported by symptom management with medications but also with quality time like arranging for a last look at the beach, or one patient I recall on a pureed diet with thickened liquids only wanted to have coffee and a donut with her daughter as they had so many times before; this was her wish so we made it happen for her. She passed away peacefully not long after. So you see, hospice is not just about caring for the dying, it is about how the dying want to be cared for. We are all going do die, the question is, how will that happen. Our goal is always a peaceful death spiritually, physically and emotionally not only for our patient but for the family as well. I hope this sheds some light on the very important and passionate support my hospice team and I provide everyday. It is difficult every day, sometimes, VERY difficult but the most rewarding and blessed honor to have, to be at someone's bedside when they die, a true privilege every day.

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