Pbrown1414

I am not new to Hospice or admissions, having worked on and off for 17 years in hospice and 37 in nursing. I find that I am taking longer than most anyone else with the full admission when eval, info, consents, and admission are needed. I am somewhat OCD regarding info and consents, making sure that patients and family understand what hospice is and is not. As I have said, this is probably the most important and emotional time in a persons life, and it is important to me that they have the right information to make an informed decision. Some evals take no time at all, considering an obviously terminal patient or disease process. And it was telling to me that ("Much of the information I need, I already have by this point") you do your documentation after the visit. I have been 2 hours driving to a patient, the full admission done, and then an hour to the next and a full admission and expected to have every little bit of the admission and documentation done. That includes calling for supplies and equipment, and medications with difficulties with ordering on tablets and with reception in the outlying areas. I have been expected to do all of this and then another if it comes up during the day. I had to leave them, even though it seemed a good place to start with, because I couldn't keep up the pace. That is what happens to us 'older' nurses. I also felt that I was being 'laughed' at because i couldn't keep up. So now i go on to other things. Maybe part-time, maybe full retirement, who knows? It is hard to give up doing hospice care. Once a hospice nurse, always a hospice nurse.

I have been a nurse for a long time, and 17 years in Hospice. Even in a not for profit Hospice, I have found that the expectations for admissions and "making them fit" is somewhat overwhelming. I am leaving my last job, disappointed that I never found a hospice I could totally believe in. I have found multitudes of wonderful hospice nurses! If we go back to when hospice really began in this country, we see a different mindset. We were doing something that felt right. We went to a person's house, sat down and really communicated. We made sure that they understood what we do, and don't do. We let them know we would "be there". That medications that would ease their symptoms would be available to them, and that it was our priority to make sure the rest of their days would be as comfortable and peaceful as we could make them. That we would be there for the family, significant other, children, and friends. we would help family and pt to reconcile themselves to the terminal disease, and make the best of the time they had left. We would be facilitators in this, their last journey. It wasn't about the numbers. the amount of visits you could get through in a day, and how quickly you could get your notes or documentation in so they could bill. Sure, income is necessary for out go, but we were not a money-driven machine. I believe in rules and regulations, because they keep us organized and productive, but not to the extent that we lose track of the original purpose of our business. Patients and families should be able to count on us to always do what is in their best interest, based on their goals, not ours. Such as; a DNR not being done. Ever. Because that is how they feel about it. And then not every discipline reminding them that they don't have one, and should get it done. Oh we don't cross the rule line, but we do hover over it. (a hospice cannot require a DNR for admission) Our job should be to let them know from the beginning that they have the option to have an OOHDNR, but it is not required. It is not up to us to make the decision for them, and I believe that our repeated mention of it tends to harass them into it. Medicare has criteria that we are supposed to meet. I always hear, "well the doctor is the one who makes the decision". Yes, he is, but he is depending on our information most of the time, and we are responsible for that information. It is not ok to lean toward one disease or another in order to get the one you want, so the patient will qualify. I think when the powers that be at medicare made the absolute criteria, then meant it. So if the patient can carry on a conversation, they are not qualified for a dementia diagnosis, no matter if they have stage 1 or 2 cardiovascular disease. And then you can't make the cardiovascular disease look worse than it is. I really don't get how these decisions are made on the medicare end. Do we absolutely have to meet criteria? or are they just suggestions? Is the doc truly the only one responsible? How much time should you spend doing an info, eval, consents and admission to hospice? In my history, there were places that had info and consents done, then the nurse would do eval and admit. That is the only way it makes sense to me. It takes very little time in most cases to find criteria for admission. You find a diagnosis, you check for the criteria, you get history to add comorbs and contributing conditions, and by the time you are done with all that, you have most of your assessment done. I know that sounds ridiculous, but actually, in a pt that has clear cut disease and symptoms, you can get that admission done in just a couple hours. It doesn't make sense to me that the office can add info and consents and think you should still be able to complete it in 2 hours. Some info visits take 2 hours all by themselves. And then you get to consents, and you have questions. It can take over an hour to do that. Why is it impossible to understand that this is one of the most important and difficult things a person or family can ever expect to do? This is emotional and hard for them. It takes time. They are upset, and they have questions. Thanks to some really hard things that have happened over time, they have some serious concerns, like "are we going to just give him morphine so he can die?". If you have worked in hospice for any length of time, you have heard this question. And many more. I do not intend to ever rush an admission. So comments? Ideas? I have retired, again. I don't expect to ever have this constant reminder of my ineptness again, but it still matters to me. A lot. Hospice was truly my niche in life. I hope this makes sense, and doesn't sound like an old whiny nurse complaining.

1. the facility is paid for basic care and medications, wound care, procedures, tube feeding maintenance, via the room and board payment by the patient or Medicaid/other insurance. that would mean that the hospice nurse would not be responsible in the nursing home setting, for passing meds and other daily or multiple daily meds or procedures. The hospice nurse is, just like at home, responsible for the education of the patient, family, and caregivers, (the nursing home nurses and aides, as well as family members providing care for the patient). The hospice nurse is responsible for the assessment and direction of care under the orders and direction of the attending physician whether it be the facility physician or the hospice medical director. That would mean, that the hospice nurse should assess wounds at least once weekly and when the facility nurse notifies her that there is a change. She should direct the wound care based on the orders and the hospice policies and procedures. 2. problems with nursing facilities are many, and there are different reasons/causes. Most assuredly, nurses that have a negative opinion of hospice, will likely be hard to win over. Hospice nurses must always remember that the facility is our client, just like the family when a patient is at home. When the family member truly knows the procedure and the medication and its dosing, we don't usually mess with them. Same should apply in a facility. The only issue I see frequently, is the reluctance on the part of the caregivers to give prn medications when they are needed. The old adage, "pain is what the patient says it is", is taken seriously by hospice nurses, but not so much by others. We must educate. I think a pain management course should be offered to the facility by the hospice, with more than one session, just like what is offered in Relias or other such educational companies. We could offer a post session discussion group with a meal or snacks and coffee, drinks etc. This would help tremendously and could be given twice a month maybe. Other facility nurses could be invited, especially affiliated facilities. Expensive? Probably. Worth it? Definitely. 3. Facility nurses can and do contact the facility physician or the attending for orders many times, without contacting the hospice nurse, or notifying her/him of the symptoms or changes that they call about. We can only continue to let them know that we need to be aware of changes and increased symptoms in order to correctly coordinate the patients care. We can also at that point, increase our visits to increase the possibility of catching these changes prior to the need for the facility nurse to address them, or call the facility daily to ask if there are any issues or problems that need attention. Increased time on our part at the beginning can help to decrease total time as care continues. Also makes for a better communication and care for the patient, which is our goal anyway. Right? 4. Medicare has stopped the use of continuous care in a skilled nursing facility with the answer that it is "duplication of services". In many cases, more frequent visits by all members of the hospice team, and possibly utilizing your volunteers more frequently as well as utilization of what some hospices call "11th hour volunteers" to provide support both physical and emotional for the pt and family can help to alleviate some of the "time intensiveness" on the part of the facility staff. Educating family in a tactful and understanding way as to the roles of the nurses and aides in the facility can also help. Normally when a pt really requires continuous care, they are at or near the active stage of dying, and the time spent is both our responsibility and our pleasure as hospice staff, No? The one thing I do know, is that attitude begets attitude, and positive is always better than negative. Whether we choose to acknowledge it or not, most people that work in nursing homes and assisted living facilities do so because they enjoy working with this population of people and they do become attached. We absolutely must treat them as family!

I have never known a hospice to refuse a patient that is on tube feeding. We have an obligation to allow pts and families to direct their own care to the extent that they understand palliative versus curative. In most cases, tube feeding is considered palliative. It certainly is not curative. I have seen hospices discharge a patient who has decided to have one inserted, as that is not a procedure that a hospice would cover, and it is usually disease-related. However, the patient who has a tube feeding inserted and it is their only form of nutrition, has the right to be on hospice if they so choose, and hospice would have the responsibility to cover the feedings and supplies including DME tp provide that comfort. It doesn't matter that we don't personally agree with a pts decision, it matters that we allow them to make it. Just like a DNR. We are restricted from requiring one, and must admit a patient to hospice if they qualify, even though they are a full-code.

of course, if the patient refuses treatment. But would they? Are they able? Do they have a POA that can make that "informed" decision? The nurse does not have the authority to tell the family to stop the feeding. That is a physicians order. Period. So is treatment of constipation and impaction, I might add. The bottom line, (no pun intended) is that the family and patient should be educated on the possibility of this complication at the beginning of their hospice journey. They should be well informed that just because a pt has stopped eating, does not mean they will have no waste or no bm. Where did you get your nursing license? Not tolerating tube feeding is the first indication of constipation and impaction. If the patient and family chose to insert and utilize tube feeding, they were more than likely informed of the pros and cons. People who come to us for care deserve to know the truth, and to be educated on complications and contraindications. No BM for 7 days is the first indication that the nurse is not paying attention to one of the most common, if not THE most common complication of a hospice patient. We know what to do about it. Every hospice I know has a bowel protocol, and the nurse in this scenario would know that. Sounds to me like avoidance on the part of the nurse, if not laziness, but it is absolutely negligence. And could be prosecuted as such, if the family knew their rights.

Oh my God! this is terrible hospice nursing! Comfort first. What is comfortable about constipation and impaction? Has the nurse even checked? Is the patient active? There are only a few reasons not to treat, but at least you check to see if that is the issue. In the preactive, active stage of dying, I don't try to treat constipation or impaction unless pt and family really want me to. I explain it, and the potential trauma and pain involved, as well as the relief, and let them make the decision. Almost all other situations call for treating the constipation/impaction.

Actually, in some states at least, it is legal as long as the physician discloses his interest prior to referral.

Well I don't know how they came to their decision, but it was the right one to make. The doctor should be reported to the AMA, and possibly you should talk to the nursing board about your responsibility as an advocate for the patient and family. At the outset, when a physician gives an order for hospice eval and treat, it should be made clear to the pt and family that they have a choice of hospices and the case manager/social worker, should be consulted to assist them in evaluating several hospices, as I am sure there are multiple hospices available to them. They should consider a lot of things, including what area the hospice services and how long it will take for a nurse to get there in times of emergency/extreme stress etc, how often the nurses come, aides come, and do they have a chaplain. What medicines will they cover, and what procedures that I need, want etc. Do they have the ability to do continuous care when I need it? Will they admit to the hospital for symptom control when they don't have continuous care? Lots of things to talk about. They would also want to tour any facility they might be thinking about. Also, not the least, they should be made aware of the possibility of taking care of their loved one at home, and what the actual need would be. Ok, I am probably speaking to the choir, but I am a pt advocate at heart, and sometimes these things aren't clearly explained to the patient, and our partners, the clinical hospital based nurses, should be taught about these things and then they would be better able to advocate for their patients upon discharge. I don't think enough is done in this area.

YOu know, getting Hospice paid for was a struggle, surely we can find a way to pay for graduated care within the Hospice framework. It would hopefully include the dme, hha and nurse visit in just a different framework. Many of our Home Health nurses already do that kind of thing. Wish we could find enough volunteers to do some of the "extras" that these patients and families need. Whoops! I forgot psycho-social people!

Well, as the original comment suggests, we are under the auspices of the medicare conditions of participation, and there are specific guidelines for the diagnosis of Alzheimers dementia. Fast of 7a or lower, and documentable decline, wt loss, non ambulatory, etc. It isn't that we don't understand that more care is needed for the Alzheimer's patient that is way above this level on the Fast, but we have to meet the guidelines, or admit to Medicare fraud. I understand too, that the addition of comorbidities can increase the likelihood of death in less than 6 months, and sometimes pts are admitted with a higher fast score. If a pt is able to communicate clearly and remembers your name, they are not appropriate as a dementia diagnosis for hospice. So you have to work harder to find a diagnosis that fits, or wait. We all know that it is hard to have a family member with this disease and the need is great for assistance with daily care and supervision. That is why we should be part of the push to get Palliative Care and Hospice together in a graduated care type of system. That way maybe we could help them sooner.

Sirius has a channel devoted just to him. Really good. I too, hope he had hospice. Every one of us deserves to have the support of hospice while they travel down that last road.

We are allowed to write orders in facility charts as long as we write them appropriately. This is usually in the contract with the facility. You should have a meeting with the facility DON/Admin, and find out what the rules are for their facility. It should specify what they expect from the case manager visiting the hospice patient. It is in the COPS that Hospice and facility coordinate care and that hospice keeps records at the facility and has records in the agency that match. When the hospice contracts with the facility, it is probably stipulated that the hospice is responsible for 'vetting' their own staff and that the facility allows and expects certain things. Your consent packet as well as your admit packet should have something stating what the responsibilities are for each entity. That way there can be no confusion. I would leave a copy of that document in the facility hospice section of the chart or in the separate chart that the hospice keeps in the facility. It would be good if your marketers could come up with a directive for each facility that you visit, that will give you their requests. Some require that the case manager always stops by the Social Workers office, some the DON, some both when they visit, just to check in. Most require that they at least check in with the charge nurse. This is South Central Texas, so I am not sure how it would work for other states, just suggestions.

I am sorry, I did not speak to the issue. I have been known to allow facility nurses to text me or call direct. Sometimes I regret it, but usually not. In a busy world, I need all the help I can get, and so does the facility nurse. Mistakes are made. We are human. You are a caring and attentive nurse. The family is ok, and the patient was well taken care of. Go on, and continue to do what you do the best way you know how, and chalk it up as a learning experience. My opinion is the same as yours, that you should have verified first, but as I said, you are human. I learned a long time ago that mistakes are learning experiences. We all hope that the mistake we make is not serious, but we all make them. Now and then I go back and think about some of the mistakes I have made in my 35 years, and realize they all made me a better nurse.

I have mixed emotions about texts. I never use a patients name or personally identifiable information, but have sent info to physicians in order to get timely responses. I have used texting back and forth from office during visits, when the info is important and can't wait, but rarely. I have asked office staff not to text when I am out, due to the fact that it is dangerous for me to read, let alone type texts while I am driving. I never have the time to stop and pull over, and traffic doesn't always allow for that anyway. My car has Bluetooth, so it is easy to talk on the phone. The only problem I have is that many times I cannot get the physician to call back unless I have texted them. so lately, I give them a quick text, (while sitting still in traffic, or stopped) to let them know I need to speak to them asap. Luckily, most of the time I am only needing to talk to the medical director for our hospice, so I get a quick response. I would suggest always having your address book up to date in your car. My set-up is such that I have to actually enter the phone number and name into the car. All of this new technology is great, and I know we will get it worked out over time. I remember doing hospice using pay-phones and Key Maps! And pagers!

one of the things we can do with a patient like this is to do continuous care for 24 to 48 hours, for "intractable pain". We can control the meds that way and get a true picture of what it takes to manage/control the pts pain. And then, if it is clear that the patient is abusing the meds and doesn't truly fit the hospice picture, he can be discharged for cause, ie "not hospice appropriate".