Werblessed

Thanks, young nurse, mimi! Are the papers and assignments fairly straight forward or a lot of busy work (research-based)?

I am looking into Chamberlain for RN to BSN this Summer/fall of 2020. I heard from other students that the online content is less brain damaging than many other programs. As a fifty-something year old student, I took the same NCLEX as the BSN students 20 years ago. I'm not super excited about having to take additional classes to be eligible to work in my field after 20 years of hospital nursing. Has anyone else heard input from former students re: less rigorous than other online RN to BSN programs? That's what I would prefer.

RN after hours weekend baylor nurse in Colorado. $38/hour, $0.50/mile and $600 every 2 weeks bonus for baylor commitment. I don't have on call unless I want it and I am off 5 days a week. I made $96K last year.

Thank you for sharing your story...really made me happy to hear others express the same blessed moment happening to them, too.

Morphine delivered via nebulizer can be very helpful in addressing acute dyspnea due to it's bronchodilator effect (however it has not been demonstrated to be an effective treatment for pain as the medication is not well absorbed systemically through this route). I haven't had occasion to work with nebulized lasix but would be interested to know it's effectiveness. Based on what I know about the absorption of nebulized morphine I would have reservations about the absorption of nebulized lasix as the medication is a loop diuretic so would have to have good systemic absorption to kick those kidneys into higher gear and work in the expected manner. Please let me know your experience and your patients response to this intervention. Interesting....

CentexRN...Physicians are among the worst prognosticators when it comes to terminal patients so I wouldn't tell family to ask the physician (especially if physician is NOT hospice physician). Families ask routinely 'how much longer do you think they have'? It is a legitimate and honest question because although their loved one's life is quieting down, their families have jobs, lives and obligations and logistically, they need to know. Of course we don't have a magic ball to be able to tell us when someone will pass but we do have physical manifestations and our own experiences to guide us fairly close most of the time. And, yes, their are always the exception to the rule (have one 93 y/o now who has been actively dying for 15 days now and we're out daily with chaplian, social worker, nurse and c.n.a.s to rally around her and ensure she has all the support and comfort she needs to leave in her own time). Dying is a process...some skip right through and others take their time, meadering and visiting along the way. What I tell families is that based on my hospice experience I would expect the patient to pass in X days/hours. I always add that caveat of "if she becomes more responsive or perks up a bit and starts eating and drinking, then the prognosis will be longer". I also assure them that our nurses and staff will be keeping a close eye on their symptoms and comfort and will be reporting what we are seeing and expecting to happen next as we go along. As to the question of "Should I call my son/daughter/cousin to come in now? They were going to come next month..." I always encourage families to have those who feel they need to be here by the patient come sooner rather than later as we don't know precisely when the patient will pass. If they are very far from the patient and I know the patient is getting pretty close, I encourage the family to get the person on the phone and put the phone to the dying patient's ear to tell them what their hearts need to say. As we know, our patients hear until the second they let go (yeah they have those awesome hospice research supporting this but we also know from our own bedside experiences, huh?) There is also an AWESOME booklet that most hospices provide to families of patients in our care. It's called "Gone From Our Sight" by Barbara Kearnes and it is formatted in very easy to read, large print. It explains what signs we typically see when patients are months, weeks, days and hours from passing and it does so in a very comforting and reassuring manner. It's a great teaching tool to give to your families and will help guide your own assessment as well. I'm not saying that I am right 100% of the time (because I don't get to be involved in that decision - it's between patient and their God) but I am pretty on the mark in the majority of the cases that I see. Maybe it's because I've worked in hospice for a while and maybe it's that 'nurses instinct' that tugs at my heart when I feel someone is close to death. I think it's a blessing because I can explain why I am expecting the death to occur in the timeframe I am seeing and reassure the family that we will provide the support and comfort the patient needs to pass in their own way and in their own time. Hope that helps. Mary

Nancy, thank you for sharing your experience...what a terrible situation you were dropped in by other members of your 'team'. I've been in similar places myself when I worked in the hospital but not quite as dire. It's scarey, it's unsafe and frankly, it's traumatizing. I don't live in New Jersey but my advice would be to go find some non-profit hospices in your area and make sure they have their own care center (those are the best situations from my own experience). Might be worth your while to volunteer as an 11th hour (when patients are very close to death but have no family to stay with them or the family needs a hospice presence while they hold vigil with the dying patient). This will get you 'in' and allow you to see what we do a bit more closely. If you connect with what you see, you could take it from there with the hiring manager who will likely be thrilled that you're a RN and have shown real interest by volunteering first. It might help skirt the issue of not having worked actively as a nurse for a bit as you'll have established a report with the organization. Best of luck to you and let us know where life points you next. :redbeathe Mary

Continuous Care is where the hospice attempts to staff nursing care for ATC care when a patient is having an issue or issues that are not well managed and require a high-level of assessment and care by professional staff. Many times these are patients who elect not to be transferred to the inpatient hospice unit (if your hospice has one) for this high level of care but wish to remain at home or ALR. A R.N. must be the one to set up the initial plan of care to include all medications, interventions and teaching expectations for all other nurses to follow and document about how the patient is responding (or not responding) to what we have put into place to 'fix' the problem. The one big snaffu in this system is when we have LPNs staffed who are not able to provide IV or SQ line care or boluses so I would suggest asking about these situations and the expectation from you when/if you are assigned as a Continuous Care nurse for a patient with IV/SC medications running. CC is one-to-one care but it can be intensive. If your patient is not responding to the interventions that were put into place by the RN, it is your responsibility to call the hospice 24/7 to report this so a RN can be dispatched to tweak the plan of care accordingly. You'll also be teaching the family/cgs in the home how to continue the care for the patient so that when CC ends (the symptoms well managed or we are unable to staff ATC) the CGs are competent to provide the care themselves. This includes bedbound care, peri-care, administration of medications, etc and is a vital function of CC nurses at the home. Hope that helps and thank you for the care you will be providing to both patients and families in hospice care.

Just a question for my colleages who've worked in this field a bit. I've had this happen to me a handful of times over many years when I worked as a PCN. I'll be sleeping soundly and just wake up and sit up "knowing' but not being able to tell anyone how I know that a certain patient just died. It's almost like they swung by to say goodbye on their way home. The first time this happened, I sat up in bed and looked at my bedside clock. My husband, Joe, asked me if I was OK and I when I said, "I'm good....Ms. X just passed away" he just looked at me strangely and said, "I didn't hear the phone ring"? And I told him that no one called but I just know. Ms. X just spiritually 'waved' to me on her way home. When the next morning, I told my husband that Ms. X did, in fact, pass around the time that I awoke, he looked at me with a bit of fear and said, "that is TOO weird...but a little wonderful too". The next several times, when I had a similar experience, he knows what it is when I wake up and look at the clock and will ask, "one of your patients just died, huh?" It hasn't happened to me since I've given up my PCN role (I work after hours and don't have my own patients). Has anyone else ever had this happen? I feel so blessed and honored when it does.

Hey, Leslie! No...I don't interpret the 'look' as terrified or fearful when our patients are communicating with unseen visitors but it sounded like imitation might have been misreading what she was seeing. Also, she reported not just seeing this 'terrified look' once but seemingly with all of her actively dying patients which is why I was more inclined to consider that imitation was misreading what was going on vs. poor symptom management. I'm hopeful that she can understand what is driving this issue and come to peace with what is truly transpiring vs. probable projection of own fears (which I agree is likely). Thanks!

Well, to be honest, there is a 'look' that patients have when they are close to death. Many of the contributors to this board know this to be true. You come in and you don't have to be within 10 feet of the patient to know they are close to death. The staring that accompanies this time is what I interpret as "visiting". Their bodies are still here but their essence (soul) is visiting where they are going to next....home. Many times dying patients will see people we cannot see. They can talk with them out loud but mostly it is a connection that you can just see....they are looking beyond those physically present and connecting with others that are spiritually present. Where do they look when this happens? In almost every situation, my experience is they see these visitors where the wall and the ceiling meet - that seam - that's where they see them (and it will be MY first question of "why THERE?" when it's my time). The look that you're interpreting as 'fear' may be an intense non-verbal communication that they are having with unseen visitors. This all sounds fairly metaphysical to all non-hospice providers but those of us who've worked in this field live and breathe the reality of death and dying. It is a process...a journey. And it is unique for every person who makes this transition in their own way, in their own time, and who let go when they decide it's their time. We, who are blessed to be working in this amazing field, get to walk along side our patients and families, educating and supporting but mostly respecting that their journey is uniquely their own. I applaud your efforts in unveiling the etiology of your concerns. I will echo the sentiments of other very talented nurses that have already replied by stating the basic truth...you must be at peace with your own mortality to help assist your patients and families be at peace with the inevitable outcome of death. And I'll ask you one little favor...the next time you are with a patient who is actively dying, deep breathe and look for something that is not fear in their countenance. Step back...you may see a non-verbal, non-physical reaching out to touch eternity instead. And that, to me, is uncountable blessings to all us of still on this side of living. :heartbeat

I think it's a GREAT transition...acute care to hospice care = excellent care giving and assessment skills! :w00t: I was just recruiting for RNs for our hospice and the mandatory requirement was at least 2 years of acute care experience, so you'll do just fine! Hospice is patient directed care vs. hospitals where it typically is physician directed care. The patient is the primary person in establishing the plan of care. How nice is THAT?! 'We treat the patient's experience - not the numbers' - you'll hear that a lot on the inpatient unit and it's true throughout this field. Yes, we do vital signs but mostly to help gauge where a pt is prognosis-wise or to provide feedback to the Attending about how the patient is doing or if med changes are needed. You're about to embark on a journey of the soul and you'll learn many little tricks of the trade along the way to help ease the symptoms of patients and provide assurance to family members. I am very excited for you...give yourself the time and patience of learning this new specialty. It does take time but with a strong clinical background I think you'll do amazingly well. Keep posting on how we can help or just to vent. And WELCOME to an area of nursing that is filled with blessings, warm and compassionate care.:heartbeat

Me too! Lots of places to learn new things and gain experience to bring to all of the patients under your care.

:cheers: CONGRATULATIONS!!!!!!!!!!!!!!!! This is wonderful! Be ready to journey into places that are genuine and connected and give yourself permission to learn and grow in your own time. I think you need a solid year of working in this field before you feel pretty OK (though we learn new things everyday). Keep us 'posted'!

It's not impossible to go straight from school into this field...it's just that you are usually alone by the patient bedside with a bunch of family looking to you for answers on what is happening. With a year or two of hospital staff RN time under your belt, your clinical skills will be solid and your confidence in your nursing judgement and assessment abilities will be strong. Plus you'll have had a lot of practice calling Physician's for med orders and advocating for your patient's needs. For your professional benefit and also the benefit of all the patients in your care during your long and illustrious nursing career...my vote is for 1-2 years of hospital nursing first so you can bring all of those wonderful and competent skills into SNFs, ALRs, ICUs and most times into the homes of hospice patients. Best of luck to you both! :hrnsmlys:

Hmmmmmmm....OK....first up, if you work in the field of hospice, you WILL (and note the capital letters) have more than one patient to care for. Most RNs have caseloads of 8-10 and at times 12-18 patients in their care. I'm not sure of the circumstance of your father-in-law's care but it doesn't sound like a typical hospice scenario. The only thing that would come close is what is called "Continuous Care" which is when a nurse (LPN or RN) is staffed to stay with one patient (usually in home care setting) around the clock to provide symptom management and assessment for out-of-control (acute) issues. But this high-care level is not for more than a few days typically so I don't think this is what you are seeing with your father-in-law. Most hospice RNs have their own patient case load (as stated above) and have to routinely see each patient 1-2x a week for a complete assessment. In addition, if a patient is having increased symptoms or problems, you may be seeing them a whole lot more than that 1-2x a week visit. I'm not trying to talk you out of this field but working in hospice care is not a cake walk though it is much different from hospital nursing. The biggest difference is the plan of care is patient directed vs. physician directed in the hospital setting. Also, your clinical skills need to be strong and you need to be confident in your practice to be a strong advocate for your patient's needs. I would recommend that you visit a local non-profit hospice near you - preferably one that has their own inpatient care center. Ask the Nurse Manager at the hospice if you could shadow for a day or two at the care center. There you will get a good feel for what we do and how we approach care issues. I wouldn't jump straight into hospice care until you have a better and clearer understanding of just what it entails...."the grass is always greener on the other side of the fence".

WOW!! Well stated, Tewdles! There is a term called "Self-determination" which I am a HUGE fan of, especially working in this field. It means that an individual not only has the right but the respect to be involved in situations that directly impact them. Family members forget that the MDPOA-thingy does not ever come into play unless and until the patient is no longer able to express his needs/wants competently - period! This is a gray area for many people - even many health care providers..but careful now...as a nurse you are legally obligated to maintain ethical standards. Having a patient being signed into hospice without their consent when they are able to make that decision independently is wrong. They may benefit from this level of care and they may need this level of care but you can't drag them kicking and screaming to the party and expect them to cut a rug! Education...with the family first (hellooooo MSWs!!) and then with the patient would be my first mission on this case. I would explain all of the benefits of hospice care (RN visits 1-2x week and PRN 24/7; labs drawn at home vs. traveling to facilities, c.n.a. assistance, DME, PT/OT, Dietary consults/therapy, 'free' medications (r/t hospice dx of course), etc, etc. And let the patient know the truth that if they improve under our careful and loving care we may graduate them from hospice and hand them gently back to their regular Physician. I've had more than a handful of families that asked me to "take your hospice badge off" before I walk in to visit with the patient, or "don't say the work hospice" around the patient. Or, more interestingly, families who asked me not to discuss death and dying around the patient only to have the patient (without family present) tell me they know they are dying but they don't want me to tell the rest of the family because they don't want to upset them. It's all about education and allowing our patients to maintain their dignity and respect throughout the death event. We are here to team with the patient and family/CGs not to get emeshed in a family dynamic that is unethical and disrepectful of the patient and the care we are blessed to provide in hospice. That's my 2 cents worth. I still think Tewdles said it better though!

FYI...unlike other care-setting facilities and/or SNFs who will usually give you a job offer on the spot, hospice is different. We are very picky when it comes to the people we select in working with the fragile population in our care. I was a seasoned RN working in hospice for years in all capacities and my current employer had me come in for 4 interviews with bunches of people at a time! At the time, I thought, "Geez...what about me is hanging this process up?" but now that I've been employed with them for several years, I understand that their mission is to get it right at the hiring time - not to fix it once you've bought it! The only hospice I've ever worked for that hired me on the spot was a for profit that was a disaster and which treated their nurses very poorly. THAT should have been my FIRST clue, huh??!! Don't be discouraged, though. Send your thank you notes to each person with whom you've met, reiterate a few points made during the interview that really hit home for you and which coincides with the overall palliative care philosophy. Let them know how excited you are at the possibility of working with them as part of a wonderful care-giving team providing such excellent service to the community. And then wait for the response - and that response may be a request for yet more interviews! Just deep breathe and repeat after me..."Only the really FINE hospice organization have the luxury of being this picky!" Good luck and let us know what happens!

If only you lived in the Denver area....sigh.... Hang in there, kiddo! Sometimes it's the squeaky wheel that gets the oil. :1luvu:

Congratulations, Charlee! Ask questions, watch the providers who have worked in this field for a bit and give yourself time and permission to learn in your own way. I am excited for you and the many families that you will undoubtedly touch in very real and sacred ways!

Confession time...I tear up from time-to-time when I am at the bedside of an imminently dying patient and family is praying. It feels so blessed and so sacred to me. I am touched and I am not ashamed of being human enough to show it. I haven't ever gone to a full-blown crying spell because as much as I connect and care for our patients, they are not our family and we will likely not be missing them next Thanksgiving or Christmas but their loved-ones will. So...tearing up - yeppa! But if I'm getting to a place where I am more emotionally clobbered it is likely because the situation is reminding me of something much closer to home (like when I care for pediatric patients that remind me of my own kids or are of a similar age, etc).

How difficult it is when our parents are leaving this world. Especially as nurses as we can sometimes struggle with the role of just being family as opposed to being the nurse, too. I am praying for you and your family. I agree that having the hospice team updated and involved as much as your mother will allow may help her hear the truth of what is transpiring, your father's journey home, in a way that may be more easily accepted. Also, if you are feeling that Dad might not be getting the pain medication adequately, or at all, it might make sense to ask the Nurse from hospice to consider a transdermal Duragesic/Fentanyl patch (if he has adequate SQ tissues) or a SQ infusion so that his comfort is ensured without having to rely on someone giving him medications routinely or as needed. Mom may also be feeling the loss of control over what is going on in their lives and sometimes this manifests itself in grabbing the wheel, so to speak, when it may not be appropriate. Again, I would speak frankly to the IDT from hospice and allow them to work with Mom so she can find peace in a journey she is making as well.

Tewdles, you are too funny! Re: time to pee...I feel like a criminal scoping out McDonalds and Convenience stores between visits just to use their restroom but rarely buying anything! It is our lot in life, I suppose (I usually hope that they cut me some slack when they see my RN id badge). The resources you listed are excellent reads and I agree that MissninaRN will get most of her education from the IDT. Most Hospice Physician's/Medical Directors are incredible teachers to new staff and are happy to share their knowledge about end-stage pathophys of various diseases. This board is also an excellent resource as we have many seasoned and well-versed nurses willing and able to give a considered opinion on what you may be facing. I think one of the most important (and first!) things I learned upon entering this specialty field was the saying, "People die the way they lived". I remember thinking, "Huh....wonder what that means?" Well, it didn't take very long to understand exactly what that means and boy, is it true! The patients I used to be most concerned about were the ones who were absolute control freaks in their normal lives or who fostered a high level of anxiety and/or friction amongst their inner circle of family/friends. They almost always died what we usually would consider a 'bad death'. What does that look like? Instead of progressing peacefully to what I term a 'turned-in place inside yourself' where people do the work they need to let go when they are ready, these unfortunate patients struggle and fight to keep away from going to that place. But they MUST get there eventually and it is so horrible to watch a dying patient struggle against the inevitable of what I perceive is facing absolute Truth (and I see that as God) without any excuses, any justifications...not so much 'judgement' but seeing your life without the rose-colored spectacles on. I've only had a handful or two of these patients and I have to pray and breathe and accept that this was their journey and respect it for what it is. And we work our tails off to manage symptoms but when they are more spiritually distressed/distraught it is very difficult, if not impossible, to provide optimal comfort as we just don't have any medications to help this non-physiological angst. I'm sorry if I got a bit off-topic...as you can see, these cases tend to stay with me. I carefully tuck them away in a very tender place in my heart and remember them and their families when I pray.

Yeah, they have Select Specialty in Colorado as well. Most of our vent patients are being d/c'd from ICUs in main-stay hospital settings as Physicians are hearing patients/families stating they want to 'go home to die'. Thank heavens we have enough of a presence within our community of providers that they know who to call when patients make this request and we do whatever we have to do make it happen and NOW! Just had a 68 y/o lady in June dying of pulmonary fibrosis on ventilator and asking to go home as first grandchild was graduating from H.S. Was in ICU on Saturday and going downhill fast. Pt was able to communicate, barely, that wanted to be home for graduation party next day and knew she was going to die soon. Bing, Bam, BOOM - she's home, we staff Continuous Care to support pt. Grandson's party is at 1400, pt. PPS 20% but intermittently aware and comfortable - passed at 1620. THIS is why I love this work and feel blessed by this profession.

Haven't worked with accupuncture. Have worked with aromatherapy for n/v - specifically peppermint oil which on occasion has worked well - others not. We also have Music Zananthologist (I'm sure I spelled that wrong!) who work with music to become in sync with the pt. energy to help regulate symptoms. Helps more with agitation vs. n/v but we've had success with both. I'm up for any holistic approach that our patients are OK with even if it falls outside of 'traditional western medicine' approach. Let me know if you trial the accupuncture in hospice and how your patients respond with this therapy. Thanks for the kudos!