trying hospice nursing for the first time

Werblessed · Oct 12, 2009

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".

tewdles, RN · Oct 12, 2009

I am re-posting something that I wrote a while back re: making a change to hospice...I hope you find it helpful.

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!

labrador4122, RN · Oct 14, 2009

thanks! i appreciate both responses. I really like the 1-1 care the RN provides for my in-law and wanted more info about it.

nursing is a lot of work, and I love about it the multiple branches within the field that it has.

Werblessed · Oct 15, 2009

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

:nurse: