Making a Difference in End-of-Life Care.

For many years, nursing facilities have contracted with hospice providers to provide services to their terminally ill patients. But few have a designated unit that specializes in providing end-of-life care. The Hospice Center, Kethley House, at Benjamin Rose Place in Cleveland, Ohio, is a designated hospice unit operating within a skilled and intermediate care facility. Opened in 1997, it is the result of an ongoing collaborative effort between Kethley House and Hospice of the Western Reserve (HWR), which provides hospice care in more than 100 facilities in the Greater Cleveland area.

Kethley's initial goal was to create a designated hospice unit to care for residents who were dying, as an alternative to sending them to another facility. Today, this integrated program combines the skills and services offered by a nursing facility with those of hospice professionals who share their expertise and experiences.

"I think that this collaborative relationship and the level at which it works is unique," says Connie McPeak, RN, CHPN, who is the alternative home care nurse from HWR and is assigned to Kethley House. "Kethley House is so committed to providing this type of care."

The commitment goes well beyond the unit's 20 designated beds. "We offer a comprehensive approach to understanding the needs of the dying person and his or her family," says McPeak. "We address the whole question of dying with dignity, and not dying in pain and alone. Our team consists of the nurse, social worker, nurse assistants, art and music therapists, volunteers and spiritual care coordinators.

"We really are the experts in aggressive symptom management and relief of suffering," adds McPeak. "By suffering, I mean all of the nonphysical issues, like the questions patients have about what is happening to them and the meaning of their lives. We are constantly doing ongoing training with the staff at Kethley in treating this kind of suffering, as well."

The benefits of having an in-house hospice program are apparent in the growth of other Kethley nursing staff, who are becoming, in their own right, experts in palliative care. Many staff members have volunteered to work on the unit and, according to Gail Anderson, LSW, social worker for HWR, the rewards are extraordinary. "One of the things we all enjoy is that we can stop and spend time with a person. You are given permission to honor that person's life by spending quality time listening and just being there."

The dual focus of the two teams enables the staff to intervene early in the dying process and, ultimately, enhance quality of life by reaching people before they reach a crisis state. "Patients get the care they deserve," says Anderson, "and the staff gets the tremendous gifts, satisfaction and wisdom that come from doing this work."

The work of the hospice team also includes supporting nursing facility staff. A monthly support group conducted by HWR offers staff an opportunity to work through their grief and helps provide closure. Along those lines, McPeak shares the following: "Recently a patient whom everyone loved died, and the staff really needed a place to put their grief. So we helped them put together a book of memories and gave it to his family. It was the staff's way of telling this patient's family what he meant to them and that his life still had meaning and purpose during his nursing home stay."

McPeak and Anderson also act as consultants to other Kethley staff who have questions about palliative care and are questioning whether a resident elsewhere in the facility might be appropriate for hospice care. They also do consulting on pain management for residents throughout the facility.

According to Anne Chance, director of professional relations for HWR, the interest in developing integrated hospice programs is growing among nursing facilities. "In the past," says Chance, "their focus was primarily on rehab and skilled care. It has shifted to the point that facilities want to promote the fact that they offer hospice care."

HWR is currently working with other facilities in the Cleveland area to develop programs that fit their specific needs. "At the core of a successful program is getting teams together and really making a commitment to integrating services," says Chance. "It is important that the patient and family see a unified team."

Adds McPeak, "In our culture, we are not comfortable with death, and we really do not know how to 'do' death. We are helping people do it differently."

Anne Chance, RN, BSN, director of Professional Relations, Hospice of the Western Reserve.