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Topics About 'Hospice'.

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  1. There has been a lot of talk about the amazing, dedicating, and hard-working ER and ICU nursing teams during the COVID-19 health crisis in the United States. Through the media, we are hearing the stories of the ER and ICU nurses working long, sometimes double, shifts to provide care and compassion to all of those unfortunately affected by COVID-19, and the beautiful touching stories of holding patients hands when their family can not be at their side. We are hearing the stories of the risks involved in their health due to the limited PPE available, and the gut-wrenching stories of nurses emotionally supporting waiting family members. We, fellow nurses across the nation and even the world, are hearing and listening about these nurses, and we must say that we are all proud to be a member of the nursing world at this time. I have never been more proud (and yet scared) to be a nurse at this time. However, we can't forget another group of nurses that are suddenly finding themselves working harder than ever - our Hospice Nurses. Dealing with the Rise in Hospice Admissions and Deaths Hospice Nurses are having a sudden increase in visits to patients, having to manage end-of-life symptoms, and are providing support and education to families of hospice patients. Hospice nurses are also getting busier with new admissions onto hospice services which is increasing their census. Hospice Agencies across the nation are suddenly seeing a rise in Hospice admissions and a rise in Hospice deaths since the start of the COVID-19 pandemic. The rise in new admissions include patients with a weakened immune system or advanced cancer that have found themselves suddenly positive with COVID-19. These patients are electing NOT to go to the hospital, not to seek treatment, and are wishing to maintain their comfort at their home. And, there is also another group of hospice patients keeping the hospice nurses busier than usual: Those hospice patients that were on hospice services before the introduction of this new virus into our world, are declining and dying at an alarming increased rate, particularly those living at facilities. Change in Hospice Nurse Role The new hospice patients that are being admitted onto hospice services that are testing positive for COVID-19 are electing comfort measures only (either they are making that decision independently or the Activated Power of Attorney is making that decision on their behalf). Hospice nurses have been busy helping to provide comfort and symptom management for these patients in their homes through pharmacological interventions or nonpharmacological interventions. Symptom management medications used in end-of-life have greatly increased, and pharmacies throughout the nation are reporting low supplies of these medications, including oral Morphine concentrate. Unfortunately, many of these COVID-19 hospice patients are living in facilities where there are NO VISITOR policies. These facilities are also limiting hospice team members such as Home Health Aides, Hospice Social Workers, and Hospice Chaplains - all critical members of the hospice team. Without these team members providing visits, this leaves the Hospice Nurse as the sole provider of care for end-of-life. Hospice Nurses are suddenly finding themselves in the role of nurse, social worker, chaplain, and aide. Lack of Social Interactions Equals Decline in Condition The other hospice patients that have an increase in needs have been those hospice patients that were on hospice services before the COVID-19 pandemic, that are not showing signs or symptoms of this virus, but that are living in a facility where there are limits on visitors. Hospice nurses are seeing a decline in the condition in these patients because, we hospice nurses believe, the lack of social interactions is affecting their overall health. These facility patients are unable to participate in the planned, organized activities in facilities (as they have been cancelled), they are eating alone in their rooms, they are not getting regular visits from families or loved ones or volunteers, and they are not being stimulated mentally regularly. We are seeing facility patients becoming lonely, withdrawn, sleeping more, spending more time sitting or lying down, increase in sores, and having a decrease in appetite/intake. There has been an increase in hospice deaths over the past 6-weeks in facilities, not from COVID-19 but instead from generalized decline in condition. Thus, an increase in hospice nursing visits to facility-based patients to provide end of life symptom management and pronouncement of deaths. Now, as of lately, there has been an increase in hospice admissions at facilities. Not patients who are positive COVID-19, but patients who are declining in overall health and we believe it is from the lack of social interactions. We have had more and more families contact our hospice agency requesting information about hospice services, qualifications guidelines, and many family members concerned about the declining condition of their loved one who is living in a facility. Hospice Nurses are Working Hard During this Time of COVID-19 They are working to ensure that patients are comfortable, addressing symptom management issues, helping to make sure that the patients are safe, and they are advocating to help patients understand their choices and then receive their end of life decisions. It's a wild time to be a nurse during this pandemic, especially with all the risks involved with providing nursing care. But, Thank Goodness for Nurses - THANK GOODNESS FOR ALL THE NURSES OUT THERE WORKING RIGHT NOW. Where would these patients be if it weren't for the caring, compassionate, dedicated nurses who are with them right now, helping them, caring for them, fighting for them, and advocating for them? Although the media is focusing on the ICU and ER nurses during this pandemic, there are other nurses that are out there too working just as hard, including the Hospice Nurses. Thank you ICU Nurses, ER nurses in the forefront of this pandemic. Thank you Hospice Nurses on the back end of this pandemic. And, Thank you to ALL of the nurses in between during this pandemic. There are good things in all of this -- The Nurses.
  2. Hello Nurse Beth, I’m in the middle of a career dilemma. I became a nurse after having a difficult birth experience with the nurses taking care of me in the hospital with my first born child. I had a home birth with my second, and then decided to go back to school and get my BSN (from scratch 5.5 years of school) because I want to become a nurse midwife. I got my career start as a float pool new grad, which was quite a challenge, and a great learning experience as I got a variety of training in many different med/surg/Tele environments. After two years in med/surg/Tele I made the move to labor and delivery. I have been in this role for a year. I realize I’m still “new” and I have so much to learn, but, I’m finding that I really am unhappy with hospital based bedside nursing. Even with a bachelors degree, our pay is not stable, and we are forced to use our PTO when they cancel our shifts with 2 hours notice, and if I run out of PTO I can’t take a planned week off unless I take it without pay. They run us fairly short staffed and constantly make us worry about the budget. My unit is also very cliquey. I’m experiencing burnout very quick. I felt it on medsurg when I left medsurg and now I’m feeling it again in my more ideal environment. Switching to day shift is a seriously significant pay decrease, and as the primary provider, that’s just not a reasonable option. Here’s my question: I have been approached by a home hospice for RN case management salary based position that has more of a work life balance. I realize it’s more of a med/surg role, as well as a more personal, and highly invested care role-as it’s not acute care, and I know it’s not the same as what I’m doing now. I’m scared to leave my role in labor and delivery, would it be career suicide if I figure out that home hospice isn’t for me? I am not ready to return to school just yet, as my children are still growing, as well as the market where I live does not have a good nurse midwife market. We just moved to our area 3 years ago and love it, so I’m not ready to move all of us again to a new area. I just don’t want to make the wrong choice. Dear Wants to Make Right Choice, It is a big decision. I hear you about the being made to use up PTO issue and running short staffed. If hospitals paid more attention to dissatisfiers like these, there might be less turnover. Cliques can happen anywhere, but they do tend to thrive in specialty areas for some reason. It sounds like you are leaving the hospital more than you are choosing hospice nursing. Hospice nursing can be very rewarding, but it can definitely cause burnout as well, because of the emotional strain. Is it possible for you to shadow a hospice nurse as you decide? I'm also concerned about the role being salaried because you could end up working long hours without any overtime. With documentation requirements and long hours, the work-life balance you are looking for may not materialize. In addition to the salary, look at the entire benefits package, such as health insurance, tuition reimbursement, and employer savings plan. What you do know is that you're not happy where you're at. You have been in L&D for one year. But let's say it turns out you don't like hospice care. You don't want to start a pattern of one-year tenured jobs. Once you leave the hospital, it can be a challenge to get back in. My advice is to find out as much as you can about the role, and talk to some hospice nurses so you will feel more secure in your decision. Best wishes, Nurse Beth
  3. Hi all, hope everyone is taking care out there. I am a hospice nurse, so normally have a mix of home patients, SNFs, ALFs. My county has a little under 1,000 positive cases; we are in our surge, not yet peaked. We hadn't had any confirmed positive cases at my hospice, but there was recently an outbreak at a nursing home and my company asked if I would see patients in this building and any subsequent positive cases. Essentially, I'm the "covid" nurse for the time being (no, I'm not seeing my routine patients at this time!) Any other visiting or hospice nurses in my situation? I am having kind of a hard time bcs I can't really do anything bedside. I use the facilities equipment for vitals (but can't always find it), and I bought a very crappy stethoscope that I can disinfect after use. I carry a small pile of recommendation forms in a clear plastic bag that I leave at the nurse's station so I can write out recs after my visit. Most of what I do is deal with family members who are freaking out bcs they can't be bedside. Normally I would help them facetime, etc, but I don't want to bring my tablet or phone into patient's rooms, even with plastic bags. I don't know. It just feels very surreal, and I want to make sure I'm doing everything right for myself and for my patients. I'm just wondering if there are any visiting/hospice nurses who have been caring for COVID patients in LTC settings for longer and maybe have developed a good routine? Thanks all and please take care!
  4. ws582

    A dying persons tear

    Very curious about something. I'm new to inpatient hospice and have only had 4 deaths so far. Two of the patients had a single tear. One of those patients, the niece saw her previously unresponsive aunt open her eyes wide focusing on something in front of her (not looking at her niece) then took her last few breaths. That's when I arrived I saw her tear. The other nonresponsive patient that passed did not have anyone in the room at the time, so I don't know if he opened his eyes or not, but did have the same single tear. Is this common, and do you think they are seeing something so beautiful it causes a tear, or do you think it's caused by fear/pain? Thank you in advance for your responses.
  5. Nurse Lyd

    An Ode to Hospice Nursing

    I’m a hospice nurse. At least, I was a hospice nurse until about a year ago, at which point I finally decided to choose life over death. Back then my mornings consisted of pounding the New York City pavement. I’d rush to catch the express train at the corner of Lexington Avenue and 59th Street. I worked in downtown Manhattan, and my agency’s building wasn’t far from the New York Stock Exchange. During my train rides, I’d sit next to people clad in black suits toting leather briefcases. I always suspected they worked in some Wall Street brokerage firm. We’d all get off the train and rush down the same worn cobblestone streets to make it to our desks before 9:00 a.m. I blended in pretty well since I dressed in business casual clothing. I suspect that’s where the similarities ended, though. You see, most offices in downtown Manhattan were busy crunching numbers. Mine was making sure that people lived the last few months of their lives with purpose, dignity, and grace. You’ll often hear people who work in hospice describe it as a philosophy. I’d agree with that. It’s the belief that people with an end-stage illness should maintain the highest possible quality of life. And that’s what attracted me to hospice in the first place. I’ve always seen life as being full of journeys. And to me, death is one of the most important trips that any of us will ever take. I wanted to make a difference during that process. By this time I’d been a hospice nurse for nine years. I’d been a hospice case manager, hospice liaison, hospice residence nurse, and a palliative care registered nurse (RN) specialist. At the downtown agency, I was a hospice RN referral coordinator. And somewhere in-between I’d become a certified hospice and palliative nurse too. I had several responsibilities as a referral coordinator. I reviewed hospice referrals, assessed for eligibility, and set up hospice admission services. It sounds way more simple than it actually was due to the sheer number of referrals we received every day. Not only were we covering the entirety of New York City, but a large part of Long Island too. The other reason my job was tough had to do with the complex situations that came with being a hospice nurse. You see, the role of a hospice nurse contains several jobs in one—sort of like those Russian nesting doll sets. Nurses play a vital part in a patient’s hospice experience. The hospice care team is an interdisciplinary team. But the nurse is the care team member that patients and families see and communicate with most. Thus, the hospice RN must wear several hats to deal with highly charged situations. Caregiver, teacher, consultant, confidant, advocate, you name it. A hospice nurse seems to do it all. And to be honest, I’ve even found myself in the role of philosopher once or twice. Dealing with death often brings up some heavy psychological and spiritual questions. You know Elisabeth Kubler Ross’ model of the five stages of grief? Well, I’ve walked patients through every single one of those stages. I’ve been with them from the point of diagnosis to their last breath. I’ve been with them through tears of rage, denial, and during that final point of acceptance. Looking back at it now, I cherish every moment of it. I’d gotten pretty darn good at my job. So good, in fact, that I got assigned to pediatric referrals. Adult patients are one thing, but pediatric hospice patients are a different matter. They bring higher complexity, blurrier guidelines, more emotions, and tenacious care team members. It required a certain amount of delicacy, and I handled my pediatric patients with kid gloves. I started to notice that the stress of the job was taking more of a toll on me. The constant focus on death wasn’t sitting well with me anymore. Plus, it’s never easy to deal with having to pronounce a sick child as being “hospice appropriate.” There was one pediatric case that was particularly heartbreaking. A source referred a child to us much later than they should have. It involved a delayed referral, an unclear care plan, and complicated family dynamics. This all resulted in the child dying right before the assigned admission RN was able to arrive. The conclusion was unsettling because it happened despite my team’s best efforts. After everyone's hard work, this was a devastating result to face. Unfortunately, hospice is still an underutilized service. This is due to prejudices against the word “hospice" and pre-conceived notions about it. And believe it or not, this applies to the prejudices of other healthcare workers too. Death before admission occurred way more often than I wanted to admit. Still, when it happened to this sweet child, it seemed to be that much more distressing for me. And I knew that after almost ten years of being a hospice nurse, I’d reached my breaking point. I went home late that evening. I'd finally left the office after sending condolences and finishing hours of charting. It again occurred to me that I’d seen enough death to last a lifetime. I remember heading back uptown on the train, once more sitting next to those people in shiny black suits. I found myself wondering what it would be like to get up every morning and not have to think about facing death. And I knew that was something that I finally wanted to choose for myself. I ended up going on a year-long sabbatical. I immersed myself in personal development programs, spirituality, new friends, travel, and hobbies. I’m currently embarking on a career as a freelance healthcare writer. Healthcare writing is the perfect balance between the right and left sides of my brain. It pleases both the nurse and the writer in me. And best of all, I feel completely alive when I do it. The way I used to feel when I was a hospice nurse. If I ever decide to go back to into the clinical arena, I’d choose the specialty of obstetrics. I'd spent a year in postpartum nursing and enjoyed it so much. I left after choosing to switch to hospice. It hasn't escaped me that the two other areas of nursing that interest me most involve the two bookends of life. Birth and death. My year away from hospice made me realize that death taught me more about life than life itself ever could. I’ve learned to cherish every moment, to understand that every breath is a miracle. I try to honor every warm hand, every mischievous eye, and every tear that I come across. And I no longer see gray hairs as something to fear. Instead, I see them as badges of honor bestowed on those lucky enough to have them. Best of all, I know I succeeded many times over in making the difference that I set out to make. Nurses everywhere provide an invaluable service to this world. They balance empathy and compassion with complex skills that help transform lives. They deserve all the accolades they receive and then some. And hospice nurses, in particular, are a rare breed that deserves the highest of praise. So often they're the rock of support that patients and families can stand on during the most trying times. I love my fellow nurses, and I want to take this moment to salute them all. And though I've moved on to more lively areas of nursing, I suspect there’s a part of me that will always be a hospice nurse.
  6. gsu8696

    Patches: My Non-Compliance Patient

    Pain management is a very tedious part of the hospice nurses' lives. It takes a lot of time to titrate medications, figure out which adjuvant meds will work best for each patient and provided continual assessments for each patient to ensure you're ahead of the pain (or whatever symptom you are palliating)! In hospice, pain has multiple definitions. We've all been taught, or at least I hope we have, that pain is what the patient says it is. Which is why Mr. H was such a challenge. His descriptions of his pain were very nondescript which meant that I had to pretty much try to figure out on my own what Mr. H was feeling. With his diagnosis of COPD, but multiple co-morbid disease processes going on, Mr. H's physician and I were working hard to come up with a plan we thought we provide Mr. H the best pain control. The second part of the equation was Mr. H-he was very noncompliant. Every time I made a visit I was educating him on his medications and how to take them and why he should take them the way I told him. Mr. H was in his 70s. He was a retired veteran. And he was always in control, no matter what. So I was reluctant to ask the physician to start him on long-acting pain medications because I was certain that Mr. H would not be compliant and it would be that much harder to try to tackle his pain issues. I talked at length with his doctor on several occasions. We were surprised that it wasn't so much the COPD that was his biggest issue, but his pain from all of the other abuse his body had endured over the past years. Mr. H would call his doctor several times a week about his pain as well, so the physician was eager to try something different. Taking into consideration Mr. H's long history of non-compliance, we discussed the option of starting the patient on fentanyl patches to try to get his pain under control. We decided that the patches would be the most effective way to control pain while keeping the patient compliant. I obtained the prescription for the patches at the beginning of the week so we could see how the patient was responding toward the middle to late week. I made a visit to the patient on Monday, assisted him in applying the patch, I explained to him and his wife what it was for, how it was used, the potential side effects and everything else I could think of that the patient would need to know. He was one that needed to know everything. On Tuesday I received a message that Mr. H had called to let me know he needed a refill on his patches. Knowing I had visited the patient the day before and what had occurred, I was sure the person who had taken the message had gotten the message confused. So I called Mr. H. And sure enough, he told me he was out of patches and needed a refill. Not completely understanding what was happening, I decided I better make a visit again that day. When I arrived at the patient's home, I asked him for the box the patches had come in and he gave it to me. It was empty. I began questioning Mr. H as to what had happened to the rest of the patches that had been in the box. He replied I was still hurting so I put one on each of the places I was hurting. I asked Mr. H to show me where he had placed the patches and sure enough, he had the one I had placed on his chest, two on different areas of his back and one on his abdomen and one on his knee. I quickly removed the patches which I can tell you, did not go over well with Mr. H. I finally got him to understand how to use the patches and why he needed to give them time to begin working, I never in a million years would have guessed that instead of worrying about non-compliance I should have been concerned about over-compliance! Mr. H and I had several months together after that. He always listened to what I told him and I always made sure to follow up with him. He was more than happy to adopt my nickname for him. Patches.
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