BeExcellent

I have a question about documentation in the HomeWorks program that "disappeared". I worked for a Home Health agency that is telling a past nurse employee that he must reconstruct on paper visits where visit documentation can not be found in HomeWorks. The time in /out and mileage is retrievable. The explanation is that the visit documentation did not attach to the visit. Is this documentation retrievable?

The hardware is more than adequate. Hardware and software were purchased specifically to replace paper and to implement Misys organization wide. We have just upgraded server to so more problems with multiple users synching. Tablet laptops were purchased to enhance "bedside" documentation. We have used program approximately a year. Initial implementation was a nightmare. Over 90% of nurse users do less than 20% of documentation at bedside. No one uses tablets. Integration of care plan problems with documentations is understandably fragmented. I am identifying "superusers", working on my learning curve from Misys naive to future "superuser", trying to mend fences between the nurse IT and staff. Does anyone know of, or have any Misys competency checklists? I am considering proposing a skill lab for Misys use to simulate bedside. Any suggestions to refresh this group or info specific to Misys appreciated.

Yes, it is helpful. I am glad to hear that my initial intuition was correct re:super-users. I landed in the middle of this when I took a mid-level nurse manager position a few months ago. Chart audits showed inconsistent use of the EMR with overtime and inefficiency up. I have openly addressed the issue with the clear emphasis that no one is to be blamed. Techie's say management didn't enforce performance standards related to EMR and clinical staff say they can not remember complicated executions. Currently, less than 5% of the clinical staff is doing more than 10% of their EMR in the field. They are relying on notebooks and "cheatsheets" to enter data later. Just to complicate things all players, techie's, business staff, and clinical staff all report to a different cost centers, so no line authority. It is like herding cats toward water!!

Well, Sue..., your reply made me feel like Einstein that is EXACTLY what I am attempting to do. Okay, I am of reasonable intelligence, why can't I find much info about the Misys software on my own. Is there a "Misys for Dummies" equivalent? Really, how hard can this be if it is a EMR software package used throughout the industry?

Let's just imagine like Alice falling down the rabbit hole, you found yourself in the center of a hospice using the Misys EMR system. Let's also imagine you are not a techie yourself and you find after one year of use the system is inefficiently and inconsistently used. Okay, let's add one last thing, the techie's and the nurses are now feuding. The techie's are saying,"I taught them that in class." Nurses are saying, "I didn't know about THAT!" We have great hardware, Misys is the software, limited budget and quite the impasse. If you were down this rabbit hole where to start?

Well, thanks for being there for your patients. You don't always know when but you WILL get blessings. LTC's are a business and ALWAYS interested in money. Two calm approaches may work. First, hospices started going into LTC facilities not because they are so wonderful and giving but because it was good business. Both the hospice and the LTC facility benefit by the Medicare Hospice provision. Also, I understand some LTC facilities are doing palliative care under the skilled nursing provision. In my area LTC's are HIRING palliative care nurses to coordinate this care. I am not saying this is ideal hospice care but a start. This is sometimes marketed by the LTC as "aging in place". Do your homework on who is paying for what type of end of life in like LTCF's and propose a "money for you...end of life care for them". Established hospices going into a facility will also often be generous to support the LTC with CEU supported inservices and even support many activites within the LTC remembering "kickbacks" are illegal! Be cool to your school. BEACH BOYS

As far as my frame of reference is concerned, all of us reach a point in life..and die. My years in nursing gave me understanding that the death was inevitable but HOW the person died and the impact on loved ones could be influenced for the better. I knew that I could be part of that better way and so I do hospice nursing. Probably more important than the question, "Is hospice for me?, is the question, "Which hospice is for me?".

Yes, Leslie and all, appalling. I have decided to follow ...'change what I can, when I can" and try to at least, motivate my immediate staff to the wonders of good hospice nursing.

Recently finished "Final Gifts". As said before, this is a great read. The book uses the term" Nearing Death Awareness" for the mental process often experienced as a person declines toward death. I also just finished the first of three books by Michael Holmes, "Crossing the Creek". I certainly appreciated the thoughtfulness and insight that is shared based on his experiences with the dying. The tone of the book is soft and appealing. These books help give me a vocabulary to discuss this unique process with staff new to hospice. There is value to be able to reflect on the dignity and importance of recognizing the complexity and opportunities often missed in the dying process.

I am now working in our inpatient hospice unit. I may be fretting over nothing but we don't move much less bathe patients very much. Room are assigned by shift for a bath and certainly not every pt needs a complete bed bath every day but if a pt looks "comfortable" they may not be turned or bathed for days. This freaks me out. I am very sensitive to the dying process and pain issues and all but I think gentle repositioning and bathing is a comfort and dignity issue. Any thoughts?

Okay Dokey.... Actually the term "palliative care" always makes me mad. I think IT is disgusting. "Palliative care" (to me) is care that the insurance company will reimburse and the acute care hospital will pass off to the pt and family as "quality of life" while they hook 'em up to PCA pumps to infuse chemotherapy (or terminaltherapy, as one pt once called it.) The term "palliative care" makes me want to puke. I'll go sit down now....

If your Mom does seem to need serial taps, you may consider a Denver catheter placement. This allows easy home (sterile) para or thorcentesis. I have had a few pts d/c'd from acute care with one and was amazed at the ease of use and the improved quality of life. You can find info online with a simple "how to" video. Google " Denver catheters."

I am not sure that homeopathic hospice exists. But, it isn't uncommon to have a few pts on the hospice caseload that prefers less conventional care and treatment. I think I would contact the homeopathic MD's in area and ask if they see a need. I don't think any hospice you choose would object to you coordinating the 'homeopathic pts" with agreement from the hospice med director and the referring homeopathic doctor. Just because most of the case managers may be managing pts in one way, we are all artists painting the tree in different ways. We have legal, moral and ethical codes, of course, but we have the wiggle room within our own practice to address those pts with cultural/values not in the majority. Let us know how it works out.

Most 'good" hospice nurses I know are on the mature side of life. I don't think you have to have been a nurse a long time but having life experience helps. Admittedly, hospice is about symptom control to allow calmness and comfort but it is also about helping those who are left behind to go on with life. Having an experienced hospice nurse to mentor you will help. Interestingly, many hospice nurses go into this having had an experience with a family member or friend. Treat your pts and families just like you would want to be treated and you will be fine. O and have fun!

Yes, to all. I think we need a separate thread on the spiritual aspect of a good death. Maybe this thread has just become too long and muddy for people to want to jump right in. I agree that every "midmorte" I have ever known has developed over time a strong personal spiritual beliefs. Many of us have found comfort and spiritual strength in our spiritual communities. But me having a strong spiritual conviction does not mean that I use THAT conviction to strength the pt and family. They can be helped to use their own spiritual strengths. One of the things I try to facilitate, if appropriate, is to have the family and friends start bringing in photographs of the pt. I start by noticing the photos in the home and then ask if there are photos of the pt as a teenage or a baby. What i am trying to do is show them that this dying part of the pt's life is such a small part of a rich life on earth. I love it when we have photos all over the pt room and laugh and cry at events. I know at some level tht dying pt is laughing and crying with us. What also happens is that inevitably some in the photos have since died themselves and folks can SEE that flow of life and start to part wht is happening in as part of that flow. Sad but not damaging.

Phew, another hard day of vacation. Napping, watching movies late, not traveling with the cell phone, sweet. Balance is the key to staying sane in this business. I can't herd dust bunnies much less cats when I am over tired. I finally got around to reading the article through that precipitated this thread. It wasn't so bad..except I rarely recommend support Ambien for my pts, besides it isn't on our formulary. As for physician, like nurses they come in all flavors. People drawn to hospice, I find, are usually there for some positive reason. Most of us are working on our own deep issues, if even on an unconscious level. Real money is made in other areas of health care. Have to scoot off and get rest. I might have to go bead a necklace tomorrow.

O I don't know about NH. Pt may die quickly and then CG will be left with hard to heal guilt on top of depression. Respite can be used as a middle breathing room step, if CG allows. I have gone chart combing to find secondary phone numbers of family or friends and gotten people that love the CG to rally around during this difficult decision making time. Sometimes family and friends just don't know what to do. Lastly, was the pt ever cognitive enough to indicate where she wanted to die? I hope things smooth out. Keep us posted.

Expect a big learning curving. Get a few good books. One on symptom control, Kubler-Ross, for sure and one touchie feeling book. If you haven't already, learn to say, "no", and "I don't know," in a calm mature way. "No" for when you are asked to work extra and you are emotionally and physically maxed out. "I don't know but will find out," is self-explanatory. Then read, pray, be open, ask questions and have fun. A good question to ask potential employers is, "What do you do if a nurse needs to leave the field for the rest of the day because they are emotionally spent?" Write that answer down and hold them to it.

Yup, Buba that's it. I don't want to be called a guide, though. I will leave that title to who or what-ever is with the pt during those final days. I think I want to be a hospice midwife. (Looked up midwife in dictionary. Mid means "with" and wife is an archiac term for "woman". Using that I could be a "midmorte"). Mohandas Ganghi, a Hindu said:" I love Christ, but despise Christians because they do not live as Christ lived." He also said (paraphrase)that if Chrisitians lived the teachings that Christ taught in his Sermon on the Mount there would be peace throught the world. So you are in good company, Michael ,on your reflections about religious hypocrisy. To have a time out to chew over these things is right and good. My hospice is very generous with vacation time. This week is my week to be kicking it. Some fun, some reflection, lots of reading, writing and even a massage. Houston has cooperated fully by having steady rain that gives me a clean conscience to stay in and reflect. As we continue this discussion, I want to thank all who have posted the last few months. I would be proud for any of you to be my midmorte. (Except maybe the crabby Republican. Well her too. if she can put that aside and be a midmorte.)

Nice to hear from you River. Thank you for the support. These issues are uncomfortable because they are personal and impossible to prove or disprove. At the same time, we want to help our pts and as we do so, we help ourselves. What I have learned is that that unlike parts of the birth process, death can not be controlled is the way our culture looks at control. We can be open, accepting, inviting, accomodating and artful but not controlling. (Hi to all thread readers. Jump in discussion. Water is fine.)

Leslie, yes, affirmative and right on! The issue I have been skirting than comes up with Michael's comments. My sense tell me something or someone, is helping the pt. Who knows. But I sense people often being mercifully, gently and lovingly guided through. Maybe these guides can also help pt adjust their deaths. They will themselves with this help to live to an event, an anniversay or as leslie said, until everyone steps out of the room. I think the guide may be perceived by the pt in the form that is the most comforting and the least scary to the pt. Family members that have died and young children come right to mind. All hospice nurses have had pts address themselves to someone we can't see. I once sat down on a chair and had an alarmed pt tell me, "You are sitting on the little girl!" These guides could be real spirit creatures or perhaps visions sent by God to bring us comfort and hope. I believe they are an outworking of God's mercy for people. Of course this doesn't happen in all cases and sometimes the pt is terrified. (I see terror different than terminal restlessness. And I treat them different.) Psychotherapy would say all hallucination and dreams of from within ourselves. The challenge for us is to let the process be the pts process. I had a young man dying and when i came to visit him he whispered. "I am Lutheran." I thot that of some importance since the young man had not expressed any beliefs at all, until his partner told me the sitter for him that day had spent the day trying to "save" the pt. I am not judging that action. I know it was well intended, but pt didn't like it. Is all that too out there?

Well, Leslie, ok you can be a cynic and Michael,too. Back to a "good death". We often orchestrate our own "good" deaths through our pts. I try to separate what I would want to focus back on pt. I have had a number of pts try real hard to die and couldn't. "Dammit. I'm still here." That process is so unique and so individual. Yes, I agree some can be conscious at that moment. The danger for us, is to have a conscious death as our goal. And when we struggle, view our death as a failure for ourselves. I have seen too many clergy and medical people, including nurses try to control their death and that just doesn't lead to a calm, comfortable death. Maybe, people have different deaths because of our unconscious bias. I can not read heart, so I can't judge anyone. People who do terrible things may be mentally ill or even possessed, for all I know. What will never be an the CHPN test is the question of how a hospice nurse develops that intuitive antenna for our pts and yes, ourselves that guides us to guide others into death. I liked your grandfather story, Leslie. Just when we think our hearts can't stand it, we get comfort. O The point of the fish story is that the the fishing Mom was already doing what she loved. She didn't need to acquire a fortune to do it in a bigger, better boat.

Cynic was a Greek philosopher that believed in virtue through self-control, so I am not sure if you are a cynic. The problem with all the "stuff" is that it gets distracting. There once was a young woman sitting in the sun fishing in her boat with her children. Everyone was having a great time (except the caught fish, of course). Along came a another woman to the dock. She was dressed great, looked good and was skinny ,too. "Hey, says the woman on the dock. Looks like you really know how to fish. Let me buy all your fish, then you can afford another boat. You can then hire some others to fish for you. Pretty soon you can be another Pike's Market, lots of boats, big market, you can be rich!" "Why would I want to do that?" asked the fishin' Mom. "Oh!" was the quick reply, "so you can be rich enough to fish all day with your kids." TeeHee

If I could be a new grad again , I would look for a position in a large teaching hospital that had an new grad internship program that rotated you through different area of the hospital. Man, that would be fun!

That's what makes all this so GOOD. Some art, some science and mostly intuition. In the end, the only ones to ask are those left behind. Sometimes, WE are the only ones left behind. We juggle managed care, office morons (oops, did I just let a bias out?), scared folks, juicy pts, And we struggle with our own sense of life and death. To quote a commericial. It is priceless. We could not buy the intimacy, maturity and humility that comes with open hearted hopsice work. To answer your question Michael, my big bellied pt died just fine. Not alert, liver failure dulls the mind, but just fine. He went to bed and went deeper and deeper into sleep. The day or so he was on auto pilot allowed his family to talk about the "little boy" he had been. Who is to say that he wasn't conscious behind those eyelids? Let me throw this out. Is there a difference in death when death comes swift and unexpected, car crash, fire, massive MI or stroke? Is that a conscious death? I read an interesting thing that said when black boxes as analyzed the most frequent last words recorded are expletives. Like birth, I don't think the traveler needs to be in control or retain the consciouness. For the most part, I like life just fine but I don't think I would judge it by what I experienced at birth.