Thinking about changing jobs-what do hospice nurses do whther in home or in hospice

tewdles, RN · Aug 8, 2009

Hospice nursing is a wonderful field. For some it is a calling, a spiritual path, a journey. What hospice nurses actually do is somewhat determined by the agency or organization that you work with. For instance, in some hospices the RNs may carry a significant medication kit that includes medications that would commonly be used to control symptoms at end of life including oral and injectable opioids. Other hospices use only the medications that they have provided in the patient/client home. Some hospice medical directors provide very detailed algorythms for medication adjustment in standing orders which allows great autonomy for the professional clinician in the field. Others provide a more limited standing order format requiring more MD oversight. One hospice may have admission, on call, weekend, and triage staff which is seperate from the field case management nursing staff. Another hospice may require that the case management staff rotate weekends and holidays, and they may have an on call requirement for after hours calls and visits. For those hospices that require the case nurse to take call, the rate of pay to carry the pager can vary dramatically between agencies as can the number of hours each agency may consider reasonable. For example, I worked as a FT case nurse managing 24 patients in the field and had mandatory on call of up to 150 hours/month. In my humble opinion, that was not reasonable.

Those things aside, looking at hospices is sort of like looking at baseball teams...they have different uniforms, different coaching styles, different amenities...but they all play the same game and play by the same rules. Hospice is ALL about providing patients and their families as much choice and control as possible over the circumstances of the anticipated death. The goals are oriented to dignity, compassion, and comfort. Hospice nurses become expert at symptom management including pain management at end of life. Hospice works as a team. In the perfect hospice model the patient is the head of the team...only those things that the patient wants or agrees to are actually on the plan of care (POC). That gets a bit muddy sometimes but is generally how most hospices function. The case nurse (RN) is the person responsible for overseeing the ENTIRE provision of care for that patient and family. A social worker MUST complete an assessment and plan for intervention. A spiritual assessment must be completed however, if the family declines a clergy visit the initial assessment may be verbal only and the ongoing assessment is part of the nursing and MSW assessment. There must be a medical (MD) review of the patient history and pertinent data within 48 hours of the admission. Those are the required members of the team. Bereavement is required but does NOT have to have early contact with the family or patient. Most hospices have a pharmacist or pharmD who are important members of the team and provide valuable recommendations in the medication plan. Hospices include other important team members such as hospice aides, LPNs, PT/OT/SLP, dietary or nutritionist consultants, and volunteers. In fact, hospices are actually required to use volunteers. The team is required to meet and speak about each case specifically no less than once every 2 weeks. That "talk" must include input from each of the "required" disciplines (RN, MSW, MD, Pastoral). Those meetings reflect the current status of the patient and family and is directly related to the POC. Any changes that have been made or are going to be made to the POC are explored in that meeting. These are very much working meetings, they are called interdisciplinary because they are, each discipline is EXPECTED to provide input into that case. Sometimes the managing MD is not the medical director and some hospices will invite that MD to attend, or they will telephone conference when that case is discussed. If the patient is in a SNF some hospices will include the case manager or responsible RN from that facility to participate in order to improve communication and continuity of the hospice care. One of the hospices I worked for invited families, particularly if they were having problems or concerns about any aspect of the care. It works more or less like this for the nurse... The patient is admitted to a hospice as a home or "field" patient. That home is wherever they live, doesn't matter. Doesn't matter who admits them, case RN vs admission team. They generally have a POC from admission which is related primarily to immediate need...some have significant symptom burden at admission, others do not. The case manager visits right away to provide a comprehensive assessment, usually within a few days...I try to go within 48 hours. This is a really IMPORTANT visit. In hospice relationship is invaluable. The patient and family must have confidence that I know how to help them and that my company/agency can and will provide resources for them. It is imperative that I communicate with the patient and family from visit one in a way which builds this confidence. On this visit I develop my assessment of the patient. From my assessment I will begin to develop the formal POC. As a hospice nurse I often have very intimate knowledge of these patients and families. It is a great privilege to be "included" in their lives at this momentus time. The case nurse is really the glue that holds the team and the POC together. She/he is responsible for insuring that everything is carried out as ordered and as directed by the family. The case nurse presents the case at IDT and then must follow through to insure that all approp discp are adequately notified of the POC and that those things are accomplished in a timely fashion (time frame is extremely important in hospice as one might guess). The case nurse supervises the activities of the aide and LPN, this is not just lip service but is taken very seriously and is clearly documented. The case nurse arranges for all DME and any supplies which the patient/family may require. The case nurse does constant teaching. The objective is to continually assess the patient and family to determine where they are medically, physically, emotionally, spiritually on the path to end of life. We prefer to anticipate and prepare families for the next step rather than to crisis manage although we do a fair amount of crisis management. Case managers in the field are professional drivers. I know hospices nurses who drive 400+ miles per week. Your car is your office. You must be able to organize yourself so that you can provide for your patients needs without having to run to the office (building) every day. Most hospice field case nurses have patients in SNFs and will often arrange to visit those folks on the same day to be more efficient. You learn to schedule visits geographically as much as is possible to be more efficient. Afterall, I would much rather be visiting with a patient than sitting in traffic somewhere.

Case nurses in the hospital setting vary with the organization. In my company I was based in the hospital for a period of time. I took care of the patient on which ever floor he/she was...we did not have a "hospice wing" or similar area. I provided all informational visits for families. I did all admissions during the 0800-1700 hours. I often was involved in the discharge planning for patients who were going home with hospice. In that setting the RN must be able to develop collegial relationships with the hospital medical, nursing, social work, and pastoral staff as they are often turning their work over to your team and they often have strong relationships with these families. In hospice facilities the care is very much like SNF care at face value. The shift nurse are hospice nurses but not case nurses. They provide hospice care and are good at it. They understand symptom management and hospice goals of care. In all areas of hospice nursing you may have to move, bathe, or otherwise be physical with your patient. The environment is sometimes not clean, not "safe", and not my standard for living. But, and that is a big but...it is not my standard that matters and as a hospice nurse I must be willing to accept these people as they are, where they are. The setting is sometimes un-airconditioned, cramped and cluttered. You have to be very careful to protect your aging back (and other body parts) in those environments.

I cannot stress enough how important the ability to develop good professional relationships is to this job. The patient must have confidence in you, the physician must have confidence in you, the entire IDT depends upon you to keep the ship on course. It is an extremely rewarding nursing job. It is really unlike any other kind of nursing I have done. There are dangers however. Hospice nurses must have boundaries. Patients, families, and employers will take advantage of the dedicated hospice professional. Sometimes we are our own worst enemies when we blur the line between professional and personal with our dying patients. BOUNDARIES!

As an OR nurse you are familiar with significant documentation requirements. Let me be clear that charting for hospice can really be a burden. It is highly regulated at the state and federal level. Most hospices expect "point of service" documentation which means that they expect you to complete your charting in the patient home. This is generally doable, but not always. Most but not all hospices use an electronic chart, some use a combination. Honestly, electronic is best as it provides the best continuity of communication and care between all staff on all shifts. Dependent upon the organization and the setting a typical hospice admission requires between 3-6 hours of time to complete. Most of that is documentation.

I hope this answered some of your questions. Hospice is a wonderful field. It is a great place for experienced nurses who have been touched by an end of life experience. Good luck!

Heogog53 · Aug 9, 2009

Thank you so very much for explaining the complexities of the administration and nursing care differences between hospice jobs. I very much appreciate what you have to say.

Currently, I am starting medical leave again to hopefully spend enough time time out, this time, to work hard on getting my back into some semblance of shape/strength. As much as I have loved the OR, between the heavy trays, moving tables, table parts, case carts, equipment of various awkward sizes/weights and the level of difficulty moving our semi conscious patients, I think that realistically speaking, it's time for me to go. THAT was a hard sentence to write. It's been my home for over 20 years.

Thanks for your information. Now it's time for me to start doing some hospice reading, to get an idea of how much hospice has changed since I was a student nurse doing my hospice rotation. That was in 1981, when the notion of hospice was pretty new in this country. My patient was my age, had horrifically advanced and aggressive breast cancer(which had already taken her mother, grandmother and sister). She had gotten married right out of high school, had two boys who were 10 and 12, I think. In many ways she had come to terms with her death, but she said what really made her sad was knowing that she'd never get to see the boys grow up. She had the best supportive and loving husband.

I would go home and cry my eyes out; she was my age! She wasn't supposed to be dying! And I left hospice with pain. Then came my L and D rotation. My maternity mom was again my age, a primip, lovely couple. My husband and I went out to dinner with them a few times. Comes the end of the semester, she's overdue. I wanted to stick around, but had to go out of town on family business. When I got back, there were phone messages EVERYWHERE to call the nursing school, not to call the family, etc. Turns out that right after I left, she became rapidly pre-eclamptic to eclamptic, EMS took her to the hospital with her husband next to her. She told him that she wanted a closed casket(having worked in CCU, I knew that was never a good statement). They did a c-section, but she wouldn't stop bleeding. Did a hysterectomy. Still bleeding. Got a cardi-vascular doc up there who discovered that she had a congenital aneurysm of the liver that had fractured her liver when her blood pressure skyrocketed. She died on the table. Dad was left with a healthy bouncing baby boy.

Those were two tremndously traumatic nursing rotations for me; two young women, dying at my age of 29.

I RAN away from those two areas ASAP.

Many years later, I helped take care of my dying parents. Recently, my boyfriend's mom died after 2 1/2 years of suffering with a brain tumor. He said that he said goodbye to his mother before she went into surgery for "get it all". His mother didn't come back the same. She was also told that her tumor was all gone, that it was slow growing and she should be just fine after recovery. I met her in May of last year, noticed certain neuro things about her and suggested to my BF to tell his dad she needed a new CT or MRI. Her tumor had come back-on her brain stem. I thought to myself that she'd live through the holidays and then die. I told my BF that a few months later, and sure enough, she revived for Thanksgiving and Xmas...and died soon after.

He asked me how I'd known, and I said that I didn't know how I knew, but that I knew.

That got me thinking of hospice nursing again. I hope I recover enough to work as nurse again. I know that Hospice is defintely something I'll look into.

You sound like a very experienced, compassionate and wonderful nurse. Hospice is lucky to have you.

Best regards,

Helga

Itshamrtym · Aug 24, 2009

Thank you BOTH for lovely posts. I am also a OR nurse thinking of changing careers. I was a LPN for 8 years and have been a RN for 4 years. As a LPN I did mostly peds private duty home care. Did some school nursing and LTC. I couldn't wait to get my RN so I could go to the hospital... LOL.... But, I found that I really love that one on one quality care that is given. Been thinking lately a lot about Peds onc. I have read TONS of threads on allnurses about it. Hospice has always been in the back of my mind as well. I know that I have the perfect personality for it. ARE THERE many Peds Cases in hospice???????? I'm going to research our local hospice. I have also even thought of volunteering. It would be nice to work within the community that I live in. I know that I will be doing a lot of travel though. Of course unless I decide to work @ a hospice home. We have a new one in my area. Well thank you both so much again. Loved your POSTS!!!!!!!!!!!!!!!!!!!!!!!