Hospice and the nursing home.Because nursing home staffs are expected to be well-versed in the needs of the dying, the potential role of the hospice provider in the nursing home is often overlooked and, in some facilities, thought to be non-essential. Their thinking is that dying residents are better cared for by the people who were already providing them with high-quality care before the terminal diagnosis was made. Hospice is much more than an optionally "desirable service," however; it is an essential program for nursing homes wanting to offer a high standard of care.
Nursing homes utilizing an outside hospice agency benefit greatly by eliminating the need to hire or retrain re·train
tr. & intr.v. re·trained, re·train·ing, re·trains
To train or undergo training again.
re·train personnel in hospice procedures, Medicare regulations or Focused Medical Review requirements. Nursing homes will also be able to rely upon the experience of the hospice staff for support or guidance whenever a conflict or problem a rises with a patient or family member.
The best possible scenario for the terminally-ill nursing home resident is one in which the nursing home staff and the hospice team work closely together, as a team, to plan and deliver a program of care that is customized for each individual.
Building the Team
What is the role of hospice and how should the standards of hospice care be measured? At Family Hospice, our experience with nursing homes and other LTC LTC
lieutenant colonel providers has shown us that the first step in the process is to thoroughly communicate the way in which hospice differs from other types of care.
Hospice is a comprehensive approach, focusing on palliative palliative /pal·li·a·tive/ (pal´e-a?tiv) affording relief; also, a drug that so acts.
Relieving or soothing the symptoms of a disease or disorder without effecting a cure. , rather than curative curative /cur·a·tive/ (kur´ah-tiv) tending to overcome disease and promote recovery.
1. Serving or tending to cure.
2. , care. It requires a multifaceted mul·ti·fac·et·ed
Having many facets or aspects. See Synonyms at versatile.
Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious team, including a hospice-trained physician, nurse, social worker, spiritual and bereavement Bereavement Definition
Bereavement refers to the period of mourning and grief following the death of a beloved person or animal. The English word bereavement counselors and others. Nursing home staff should understand the roles of these hospice team members, as well as what is expected from each of them.
The Hospice Physician. By working collaboratively with the resident's attending physician, the hospice physician builds upon the attending's prior knowledge of the case. It is up to the attending physician to determine his or her degree of involvement. Calls in the middle of the night, for example, are common during a terminal illness, and if the attending physician prefers, these calls and other emergencies can be handled by the hospice physician.
The hospice physician's specialized knowledge of palliative medicine also reduces the likelihood that the dying patient will endure unnecessary pain and discomfort.
The Hospice Nurse. Hospice nurses have similarly special expertise in pain management and palliative medicine. The primary role of the hospice nurse is to coordinate all patient care activities in tandem Adv. 1. in tandem - one behind the other; "ride tandem on a bicycle built for two"; "riding horses down the path in tandem"
tandem with the nursing home staff, developing a plan of care for each patient that is accessible by the facility's director of nurses.
While Medicare guidelines for hospice require one nursing visit by an RN every 14 days, Family Hospice nurses typically visit each patient twice a week because, more often than not, anything less frequent is simply inadequate. The ideal frequency for RN and home health aide services should be determined by the hospice nurse, working hand-in-hand with a nursing home nurse who, like the attending physician, is familiar with the patient's physical needs.
Though nursing home and hospice nurses have similar missions, there are differences in their respective "cultures," tasks and experience.
The vast majority of nursing home nurses are licensed practical or vocational nurses who provide bedside, task-oriented care. RNs at nursing homes are more often in management positions, with responsibilities that limit their ability to provide hands-on care to dying patients. The opposite is true of RNs who specialize in hospice care.
Early on, it is important to determine which activities should be handled by the hospice nurse and which by the staff nurses. Some nursing homes, for example, prefer that the hospice nurse be responsible for pain medication orders related to the terminal diagnosis, while others prefer that their staff nurses undertake this task. It is up to the nursing home to make such decisions.
It must be emphasized, however, that the hospice nurse is essentially an "outsider" who is invited into the nursing home via a contractual arrangement. The hospice nurse must learn and follow the facility's policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental . Establishing a real sense of teamwork early on is the best way to overcome or avoid territorial issues and to build mutually beneficial Adj. 1. mutually beneficial - mutually dependent
dependent - relying on or requiring a person or thing for support, supply, or what is needed; "dependent children"; "dependent on moisture" relationships.
"Elizabeth," a Family Hospice patient and nursing home resident, is a good example of this team-based approach at work. A 79-year-old widow, Elizabeth was diagnosed with end-stage dementia. Unresponsive unresponsive Neurology adjective Referring to a total lack of response to neurologic stimuli and experiencing little, if any, quality of life, she had previously prepared a living will and had emphatically em·phat·ic
1. Expressed or performed with emphasis: responded with an emphatic "no."
2. Forceful and definite in expression or action.
3. stated that she wanted to die naturally, with no artificial life support.
A feeding tube feeding tube
A flexible tube that is inserted through the pharynx and into the esophagus and stomach and through which liquid food is passed. had been surgically implanted prior to Elizabeth's terminal diagnosis, and her son was faced with the heart-rending dilemma of deciding whether to continue the tube feeding tube feeding,
n a method for supplying liquid nutrition through a tube that passes through the nasal passages and into the stomach. This method is utilized when ingesting food through the oral cavity is inadvisable or painful due to surgery or injury. or to follow his mother's express instructions. Both the nursing home staff and the hospice team worked together, providing her son with the information and support he needed to make his own decision. In the end, Elizabeth's son honored his mother's wishes, both documented and verbalized, and decided to discontinue the tube feeding. Elizabeth died within 17 days.
Spiritual and Psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. Care. Many people don't realize that hospice is much more than palliative medicine. A truly effective program of care includes social workers, bereavement and spiritual counselors, and volunteers.
Some state regulations call for a nursing home to employ one full-time social worker per 121 or more beds. These social workers are stretched very thin in their efforts to help more than 100 people and their family members at any given time. The hospice social worker can often lighten light·en 1
v. light·ened, light·en·ing, light·ens
a. To make light or lighter; illuminate or brighten.
b. To make (a color) lighter.
2. this caseload case·load
The number of cases handled in a given period, as by an attorney or by a clinic or social services agency.
Noun . A social worker specializing in the needs of the terminally ill Terminally Ill
When a person is not expected to live more than 12 months.
Any gifts given out by the afflicted person at this time may be considered as a dispersion of the estate rather than a gift. not only helps to address the patient's psychological issues, but also plays an instrumental role in educating the family on what to expect as the illness progresses. On a more practical level, the social worker can also assist with advance directives Advance Directive
A document expressing a person's wishes about critical care when he or she is unable to decide for him or herself. However, it does not authorize anyone to act on a person's behalf or make decisions the way a power of attorney would. , living wills, guardianship plans and other issues.
A hospice-trained social worker does not, however, eliminate the need for a spiritual counselor. The chaplain can provide comfort and spiritual support to the nursing staff as well as to the patient and family; in many cases terminally ill patients have been residents of the nursing home for years, and staff members consider them "part of the family."
Specially trained volunteers also play an important role in the day-to-day routine of a terminally ill individual. By establishing and building supportive friendships, volunteers can help make the patient's last days of life more fulfilling.
Hospice as Educator
Another important role of the hospice team is that of educator - educating the nursing home staff about hospice and its benefits to patients. Even though hospice care is much more prevalent than it was a decade ago, many health care professionals have only a superficial knowledge of it. Hospices can also provide inservice training to nursing home staff on such topics as pain management, HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome , death and dying, and issues related to grief and loss.
For qualified patients, Medicare (and Medicaid in states where available) covers the entire cost of hospice services. There are no deductibles or copayments for routine home care, continuous care or general inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital . Physicians, RNs, home health aides, pastoral counselors, social workers and volunteers, as well as medical equipment used, are all included, and drugs can be.
Other sources of payment include private insurance, HMOs and personal payment. Individual payment plans can be developed to meet specific needs and, in many cases, non-funded care is donated for needy patients.
Understanding hospice's comprehensive approach to care can make a major difference in the overall quality of care the nursing home provides.
When experts in hospice and nursing home care join forces, the end- result is a team - and a level of quality care - that can make beautiful memories of the time that patients and families have remaining.
Mary Lou Gillespie is Chief Hospice Officer, Family Hospice, Ltd., Dallas, TX.