aimeee

There's a long list.... strong assessment skills, ability to "connect" with a wide variety of people and yet maintain boundaries, good listening and communication skills, teaching skills, time management and organizational skills, team player, critical thinking skills, ability to prioritize what HAS to happen today and what can wait, ability to leap tall buildings in a single bound... oh, wait, sorry. Got carried away.

There is no specific requirement to gather MAC in the new cops. What the new COPS require is a form for the gathering of data elements to be utilized in your QAPI program. It is up to the individual organization to determine what form will be used, and what data will be gathered on it.

We have some male nurses and age is only a factor as far as it correlates to limited life and professional experience. Each person must be judged on their own merits. Some people have more experience and maturity at 20 than some ever achieve in a lifetime. But the tendency is that the younger nurses haven't had the experiences that bring them to a place where they can deal with the breadth of situations that they encounter and to know that this work is something they really want to stick with. Energy, passion, and a willingness to learn go a long way though.

Yes, there is a core curriculum and a study guide. Your most economical alternative is to purchase a membership in HPNA and then the cost of the test is discounted and so are the study materials. If you go to the HPNA.org website you will find links to all the information you need.

I agree with the above... they should cut out the requirement to be at IDT's. 1 person per 70 is definitely justifiable at full time, especially on the weekend. We have a census of about 200 and have three people covering call. On the weekends we also have a phone triage nurse because the call volume is so high. And although you can't be paid extra for holidays since you are salaried, they should give you some sort of compensation, like an extra day off somewhere else.

That sounds like a policy that is not patient service driven. In fact, your post shows the unintended effect... the difficulty of obtaining the medication is driving use instead of what would be the best medication for relieving the symptoms. The trouble with CIII's is that you quickly reach the ceiling dose so if your patient is in a pain crisis they are out of luck.

We have standing orders that allow us to titrate the dosage up another 50% if necessary to achieve relief but after that we would have to call the physician to get an increase. If you are doing hospital nursing you will probably not have such liberal titration orders. The principle you are referring to is that of "double effect".

Freedom? That's an interesting word I never would have thought of applying to hospice nursing. Autonomy maybe. It certainly can be stressful, or it can be delightful. It all depends on what comes about. Certainly every day is different as no two admissions are alike. Every patient, every family is unique. I'll tell you what a day is like under our model, but recognize that many hospices use different models for admissions. The day generally starts with coming to the office and updating the laptop and pulling in information about the days assigned admissions. Usually we do two, but sometimes the plan changes at the last minute as to which ones we will be doing. Lots of times referrals are made at the last minute so there is often shifting of assignments to meet the needs. You learn never to get too mentally attached to any plan for the day. You head out for the appointment. Spend maybe 20 minutes talking about hospice, showing the patient/family how it will meet their needs, getting papers signed. Then about another hour assessing the patient, making a med list, careplanning and educating the family, ordering equipment, collaborating with other team members etc. Then there is about another hour of charting and phone calls to do getting that all typed out in the computer. If there are medication changes needed to get the person's symptoms under control (and there often are) that can add to the time involved. If things go smoothly, it will take close to 4 hours all inclusive. If there are a lot of hurdles, it can easily expand to 6. We do A LOT of stuff up front though. Some hospices do less on the admission visit, and may even have a rep who goes in before the nurse and explains about hospice and gets all the consent forms signed. In those situations, the admissions nurses generally do 3 admissions or even 4 in a day.

We cannot exclude patients due to full code status. It doesn't make much sense to be a full code when terminally ill.... but still... some can't bring themselves to sign a DNR. Sometimes it means no one has really educated the family on what running a code really looks like at time of death. It looks so easy on tv... one little jolt with the paddles and the next minute they are sitting up in bed joking with their loved ones again. Usually the family doesn't actually want the code done when it comes down to the last minute, but some do.

It runs the gamut from people who just need a little reassurance or have a question about a medication to a patient that has just decided constipation is an emergency to a family freaking out because they are suddenly confronted with the reality of death. One night there may be no calls, another it may be constant. There is no typical. You will get a sense after a while of who needs a visit right off the bat and who will be fine with a little advice and teaching.

The small numbers may reflect that while few people actually MAKE the choice, they want to be able free to make it. It may reflect that we have deep taboos in our society and makeup about taking our own lives that keep us from doing that even when we have the means and the freedom.

I think it is just another euphamism for dying that is coming more and more into vogue. And like the word dying, it all depends on how you define it. Dying can happen in a day or it can be a lengthy process that takes weeks. We had a discussion about the terms active dying and pre-active dying a while back. If you include the pre-active stage of dying and are utilizing term transitioning instead, it could be a two week window. Its more what's happening than a precise amount of time.

I'm personally uncomfortable with it but I support self-determination. My father is a member of the hemlock society and I would want to be able to support him.

I have never heard of that one. I'm skeptical.

Hi Emilie, Guess you didn't get an answer in time for your interview. While a deeper and broader experience would prepare you better, your heart for the work and your communication skills, your honesty, and your outward presentation of confidence will help you succeed. Even the most experienced of us sometimes encounter situations we are uncertain about. Its all part of the learning and growing. And btw, I'm the one you interviewed with. Welcome to hospice, Emilie. :)

I started as an admissions nurse in hospice care after experience in long term care. It worked well as a transitional role for me. As an admissions nurse the main focus is on the documentation of the baseline condition of the patient and the history and appropriateness for hospice care (how well they fit the medicare guidelines) and identifying the most crucial issues for the care plan and getting things started. Collaboration with the team is not only expected, but required, so there is a lot of learning that happens with that process. Explaining the hospice benefit and obtaining signatures may also be a part of the admission process depending on how your hospice handles this (it is in ours but many use social workers or "program reps" to do that part). It takes longer to develop the expertise in the symptom management areas because you don't get to see first hand the results of interventions that you put into place. You have to seek out that information by talking with the team. But there is a lot less pressure to know how to handle everything because you know you will be handing things off immediately to someone more experienced. And, unless you work for a very small hospice, likely your knowledge level will be part of what's taken into consideration when admissions appointments are assigned. It certainly would be in my department. If we are admitting someone that we know has a lot of difficult issues, we would try to match that person with an admissions nurse that could best address them. We try to give the "green to hospice" nurses the more straightforward admissions at the start.

This article in Scientific American's Mind and Brain suggests that research has not found supporting evidence for a progression through Kubler Ross' five stages of grief, despite the theory's popular acceptance. http://www.sciam.com/article.cfm?id=five-fallacies-of-grief

Evaluate and Treat is an open ended order that is used for the Nurse Practioner to make a Palliative Care visit. Perhaps they have some confusion and are working with multiple programs?

These are gray and much debated areas. You cannot discharge a patient for going outside the plan of care. There are only three reasons you can discharge a patient: 1) They are no longer appearing to meet the criteria for terminality....in other words, it appears that their prognosis is greater than 6 months. 2) They move out of your service area 3) You cannot provide care to the patient without endangering your staff (but you must document your attempts to work through finding ways to make it safe) The patient/family can revoke their hospice benefit for any reason, or no reason at all other than whim and they don't have to tell you why. There is no such thing as an automatic revocation because they choose to go to the hospital. What you can do is have discussions regarding what makes sense as palliative measures to treat their symptoms. If you feel they will choose to go outside those measures you can provide them with an ABN, a notice that you will not be paying for those measures outside the plan of care and what the costs would be. They can then make an informed choice. Now is a good time for the team to have a goals of care discussion with the family see if you can all agree on how things will be handled. Perhaps they could have the UTI treated as part of a GIP admission instead of revoking their benefit and going off on their own. In this way, their continuity of care could be maintained. Discharging automatically after 30 days is going to be a red flag and I would wonder what the justification would be for it if I were a surveyer or reviewer.

Its still rough for now but within a couple of years it should be much better....the conditions of participation for nursing homes are being revised just as the hospice ones have been and when they are finished (they estimate they won't be ready for another year or two) they should mesh with the hospice ones. Won't that be something!?

We have the standard kit from Hospice Pharmacia.

Not normal, but we do it now and then when it would otherwise be a barrier to them getting started on hospice. Usually its the young patients with ovarian CA. I don't think we have ever had a lung CA patient on TPN.

As far as them d/c'ing orders without consulting you, you may need to gently remind them that it is HOSPICE who is supposed to drive the plan of care. If the care plans don't dovetail, THEY will be sited as well.

Well, we don't "eat our young" in my organization, but you would need to have experience before you got here in order to be prepared to face the daily challenges. I found that when I started spending several years on a LTC skilled unit was very helpful and having a more stable population was also a plus. We do everything we can to mentor our new employees and help them develop good time management skills and support them emotionally as well.

Even when feedings stop, waste material continues to be produced. I would give the meds unless there is an indication that intestinal distress is being caused by them. I have had people who had impacted stool that were dying. There's never a GOOD time for disimpacting someone, but it seems to wrong to have to do it during that sacred process. Keep those bowels moving as long as you can.