andyg

You can always discharge due to the patient seeking treatment at a hospice non-contracted facility. I am sure when you admitted them you explained which facilities you contract with. This covers you under the guidelines and you can readmit upon there return to your area. That way everyone gets what they need i.e. the patients gets the necessary treatment and hospice stays within guidelines and the hospital gets reimbursed as they should. Hope this makes sense. andyg

I agree with all the above. I've been doing hospice about 14 years now and learned long ago yu can't do it all. I always made it a point to go to visitation for myself and the family (it is also very very good PR for you and your company) this doesn't take very long because theres always others in line. The FH folks also get to know you personally and that can make your job easier at times. Let me say that the ones I visited were the ones I got close to but also if they were well known in the community it never hurts to do some PR for your company especially if you have competition in your area. Good luck andyg

Yep I reckon for the most part I am. Since you are a pretty little motivated individual get those others motivated with you and good luck.

Put my two cents worth in, had some fairly good results in days gone past with some of our end stage COPD'ers, in agreement with the SL working better for pain most of the time but as some have said "what they truly believe will work, what they don't believe in rarely does" andyg

Very interesting to see the various thought processes on this issue. It is not a requirement by JCAHO or Medicare to do VS. This would be more of what your agencies P & P manual had in it. My own thought process is that a lot of the time this will increase a family and patient's anxiety because then they are concerned with it being to high or to low. At the same time depending on the patient's phsyical status you can almost bet it will be pretty elevated (increased pain or discomfort or anxiety) or pretty low (patient actively dying) so it will almost always vary. If it is elevated or low the patient or family will want to know what you are going to do to "fix" it. I do agree there are many times by doing these assessments it does make both family and patient feel that they are not dead yet and that you are truly taking care of them. So I guess my feeling is it based on their current "needs" and is uniquely individualized on each visit as with every other aspect of Hospice care. Andyg

chris, when I read this I thought it's a wonder you haven't had a bunch of thoughts shot at you. My opinion is they are completely different specialties with completely different goals with completely different COP and standard requirements with completely different staffing and visit differences. I guess my point would be they are completely different from many aspects. State inspections are somewhat the same but a surveyor looks at different areas of care for each. Marketing is essentially the same cause all you are doing is seeling your product and company. My best advise would gather your staff and get them behind you utilize their knowledge and create some enthusiasm because their morale is probably pretty low right now. Your staff will be your biggest ally in keeping your program from sinking. Good luck. Andyg

I decided that we would use admission nurses at our agency for several reasons. 1st it would provide the case managers additional time to spend with their case loads. 2nd the patients and families would get the "same" story from each of the admission nurses and have less "stuff" that was missed during an admission. This was happening alot with folks that didn't routinely do admissions. 3rd is I could use two to four of my part-time or registry nurses to do nothing but admissions. The admission nurses really enjoy this role and I've not had any of them complain. They also have good working relationships with many of the hospitalist and other docs in the hospital because they also do our hospital referrals. The paperwork is lengthy but once you are familiar with it you pretty much breeze through it. You still work closely with the case managers as what you've seen, done, needs to be done etc when you give them report. Good luck andyg

Hey there req read, Go to the opening page and log in, go to the 11th bullet under technical assistance, then go to the 13th bullet titled suggested staffing ratios and it's all right there. Good luck andyg

We go over about 100 patients in approx 1-1/2 hours and cover the areas actually quite well. In fact the last medicare and JCAHO surveyors sat in on the IDT meetings and was most impressed with the information we covered. I really feel it is not the "lentgh" of time but what you are able to accomplish in it. We have broken our areas down for the CM to include discussions or reports on new admits, patient with no changes and they just list them, patients with decline and patients with new problems. All our staff are involved in these discussions including Medical Director, CM, other RN's,CNA's, SW's, Chaplain's and Vol coordinator, etc. Now we truly have teams that care for the same patients all the time and they discuss these patients especially the ones with changes pretty much on a daily basis. andyg

In reponse to req read's question NHPCO has some recommended staffing rations on it's web site. I believe if you go into the main page then into the inside NHPCO then to technical support that they have recommeded staffing ratios for all disciplines. Hope this helps. Andyg

There is the internal pacemaker which will keep the heart rate essentially "normal" but it usually does not "shock" and will not really affect the patient because of chemical changes within the body hen the patient is actively dying. The internal defib will and can "shock" the person just as if you were putting the external defibs on a patient to shcok them into a normal rhythm, the magnet when taped in place will deactivate the defib so it doesn't work. In response to beexcellent, the manufacturers of the internal defibs have the magnets available and the ones I've seen and used are indeed the same size and looks like a donut, I'm not positive but I would say the size did matter because it probably has to have a certain strength to "de-activate". Andy

Have had some diffcult N/V cases over the last 15 years and the good ole standby for me has always been Haldol on these difficult cases. Usually in cases like these I'v eput in a SQ butterfly in the abdomen and covered with opsite and cap. That way the family can give injection into SQ tissue without actually giving "shot". This was used a lot before we got into all the topicals and SL meds. Topicals are ususally limited by dosing and SL can increase the nausea. Good luck

We have run up on this on many occassions. Ususally it has been our experience the "defibs" were placed due to other helath problems in the past and usually has nothing to do with their terminal dx. Once the DNR is in place we will usally start teaching the family concerning how these work and the possibility of "shocks" after the patient has expired and how this could injure someone else. We actually have taught the family on how to tape in place or we try to do prior to the patient actual death. Just an FYI we have contacts with the manufacturers rep and all we do is call and they will send us a box of magnets to use whenever we need them. This way there is no cost involved.

I totally agree, I do think a lot of the "newer" Hospice nurses really have not had the opportunity to distinguish between religion and spirituality. In our culture a lot of folks still think these are the same. I still have trouble at times with my staff and even my chaplains understanding the difference and beleiving that everyone has to be "saved" to go to heaven or the other side. I think by me understanding the difference it has made my out look on life so much better. Keep the faith my brother. Andy

One of our most memorable family events was when a family called and asked me if it was okay for her to bring some food over for the staff to show how appreciatvie they were of the Hospice team. To my and my staff's surprise the whole family (daughter of patient and her husband, three young adult children) showed up at 0745 for our IDT meeting. They drove two hours to get here in the pouring rain and all the food for about 30 staff was home baked and cooked and "still warm" so they had been up cooking since very early taht morning. But the most impressive thing to top all that was they alls tood in IDT and essentially gave a "testimonial like I've never heard" praising the staff and what we stood for. I've got to tell you every staff member came out of there crying and feeling very good about what they do. Good luck.

After 15 or so years in Hospice I think several areas paly a role in someone hanging on. I think first and foremost from what I've seen that someone who has been "bad" for many years ie. abuse, neglect of someone, "sinner" etc are more scared of dying because even though they may not voice it they believe in "hell" and so they fight to hang on. Others that are "at peace" with themselves and know their families will be okay tend to go without such a fight. One of my most memorable patients that I still think about ask me several questions that were harder to answer than most: what will it feel like, I mean actually feel like when I die? Will I know when I am dead? Will I be able to see my body when my soul leaves it? Will I still think like I do now? This young man was only 36 years old but was okay with dying. I guess to answer your question I think each one has to be at some pint with their inner selves to be okay with dying. Andy

Hi, ya'll thought I'd put in my two cents worth. I live in Trenton and have worked in Jackson the last 12-13 years. Welcome all you nursing students and good luck Andyg

Congrats, I'm glad it's going well for you. One word of advice would be to just treat the deceased and the family with respect and you will have little to worry about as far as specific stuff you have written down. These folks just need a little love, tenderness and caring at that particular time and you are just the one to give it to them. Good luck in your future learning experiences as they will be many and never ending. Andyg

Felixfelix, I'm not sure of where you live but most of the hospices in this part of the country do not require 4 yrs. (South East). I do agree that it does how you present yourself when interviewed as do all jobs. We have hired new grads but the main reason they require some experience is because of assessment, as well as, being able to handle psychosocial issues that you will be faced with. Also, Hospice has a reputation as a high burn-out field and unless you are mature with life experiences you are vulnerable to this. Hope this helps. Andyg

Hey doodlemom, you don't say where you're located. I know here in TN that many nurses want additional hours and are willing to do extra. So you might try posting at your local hosptial and checking with some of the HH agencies in your area. Another thing we have done is (we are part of a hospital but seperated) to orient nurses from the oncology unit during their hospital orientation. That way they are a little oriented to Hospice and we can use the Oncology nurses if their census drops. Hope this helps and good luck. Andyg

Hi, JudithLane Many programs I'm aware of do not use LPN's and some do, but you need to consider several things. Yes you can complete in one year but financially an RN's salary is much more and opportunities are actually much better. You didn't say what state you were from and many states are actually looking at decreasing LPN's. Good luck in whatever you decide to do.

doodlemom You can find this inof on the NHPCO website, once logged into the opening page go to technical support then go to the 12th bullet, suggested staffing ratios, and there you go. Good luck with your new manager, hopefully she will utilize your nurses expertise and input before making major changes. Andyg

Congrats, we can always use more compassionate nurses that are willing to take the jump. One of the books that we use with each of our nurses in orientation (and they get to keep the copy) is "Notes on Symptom Control in Hospice & Palliative Care" by Peter Kaye. It is available through the Hospice Education Institute and I believe NHPCO, also. It list various symptoms from anxiety to pain and restlessness and gives rationale for these occurring as well as suggestions to use to combat these symptoms as well as medications and dosages. In the back of the book it list many of the common cancers and symptoms associated with these and treatments and potential problems areas you might encounter. I highly recommend for someone new to Hospice to read but until you get some confidence to use prior to a visit for a specific disease so you have some knowledge to answer questions with. Good luck in your new future.

I feel your pain!! Our nurses right now are carrying 14-18 patients per case manager but that's because of the amazing growth we have seen over the last four months from adc in August of 92 and now up to adc 115-120 and administration hasn't approved new positions. We have pulled in all part time, registry and weekend nurses to assist with making visits. One thing you might use with your mgt. people is the NHPCO's staffing recomendations on their website, it suggests 8-12 patients per case manager. You didn't say whether this is a constant load or whether your staffing or census patterns had changed. Good luck and hang in there at least these patients are getting some attention even though it may be limited.

Most nurses I have known and thought of changing jobs have always been concerned as to whether they could do Hospice or learn it. These are there biggest fears. I have actually hired two dialysis nurses who do a wonderful job. Hospice has to do with your heart and the rest comes after time. Humor is the best medicine made and will help you and your patients/families deal with even the most difficult situations. Hospice has been my calling for 15 years and hopefully 15 more and I can't think of doing anything else. Give it a try and you will know quickly whether it is for you or not. I bet the first time that dying patient looks up at you and smiles and thanks you for treating them like a person and keeping them comfortable, you'll know. good luck. Andyg