Midway through my nursing career I took a break from the chaos of critical care to try a different area in the healthcare field. To many people’s surprise, a month after my own mother’s sudden passing I took a position as a Hospice Nurse.
For those of you unfamiliar with the term, Hospice is a form of palliative, or rather end-of-life care. When an individual has come to a place in their chronic disease process where no amount of medical intervention can reverse the outcome of their illness, they may decide to take the course of hospice care.
Hospice/palliative care doesn’t mean you’re giving up on life. No, it means you wish to live the remainder of your time on earth with dignity, savoring your life and living it as you wish. You decide to forgo painful medical interventions that will have no positive long-term effect on your illness.
Hospice turned out to be so much more than I ever thought it was, and to this day it is still one of my favorite areas I have worked in. I learned a few things in my years as a hospice nurse, and I also realized I had plenty to keep me busy.
It turns out that patients who had a chronic condition, that would sooner rather than later take their life, still had many of the same needs an acutely ill patient possessed. They still experienced painful urinary tract infections that could be treated easily, or fluid on their lungs that might be lessened by a dose of diuretic. So even though they were in essence dying, for the time I cared for them they were still alive, and as such deserved my full attention and care.
My first month on the job I discovered some physicians less than eager to provide me with the necessities for these patients. I’m not sure if they expected that once they signed off on Hospice orders for a patient that their job was done, or if they just didn’t feel it was important to treat a person who was gonna die soon anyway.
It turns out some doctors and nurses get Hospice, and some do not. When I returned to the intensive care bedside I realized the same held true. It’s a difficult situation to make a patient a DNR (do not resuscitate), but becomes even more difficult if everyone involved doesn’t understand what this may entail.
DNR does not mean “do not treat.”
A Hospice patient may enter the hospital for treatment of an acute condition not related to their chronic condition for which they receive end-of-life care.
If you had a painful fracture would you want it treated?
If breathing was difficult for you would you like some oxygen?
If running a high fever caused uncomfortable tremors wouldn’t you want that fever treated?
If a little Lasix could lessen the feeling of drowning in your own secretions or painfully tight edema, wouldn’t it be worth administering?
If turning and positioning will prevent painful bedsores, then why not?
In the end the decision to treat a chronically ill patient is determined per the patient’s wishes, or in lieu of their orientation and ability to verbalize, a family member’s consent. But as a patient’s health care advocate we must all widen our focus when it comes to palliative care.
Treatment of a patient who is a DNR is not black and white, and each decision to treat should be based on the best outcome for the patient. Despite a patient’s eventual passing, they still deserve treatment in their best interest.
Pain should not occur, period. And any acute condition that could be treated effectively should be done so regardless of the patient’s chronic condition. Unless treatment will cause more pain or discomfort, it should at least be offered, and certainly not withheld.
Whether a patient is expected to live a day or fifty more years, they have one big thing in common. They are human beings who deserve appropriate care and have the right to dignity and respect during that care. How we provide that care will be altered in respect to a patient’s disease process and likely outcome, but care should be provided no matter what.
A good rule of thumb is to picture a patient as your own personal family member. What would you do, how would you proceed?
DNR, Hospice Care, and Palliative Care are all wonderful things in my opinion. They allow a patient and their family the freedom to pursue life on their own terms, with dignity and autonomy. Despite any decision on their part to stop interventions that will have no longstanding effect on their eminent death, we must always be available to provide the care that they do need to make their remaining time easier.
Mischa Ambrose says
Thank you so much for this. I am currently a hospice nurse. It is the most wonderful, frustrating thing that I have ever done. But, I do know that this is my calling…
brieann.rn@gmail.com says
It is a very special calling. God bless you for your service.
Anneta Moore says
A wonderful piece. My husband was given the most precious gift of care from Hospice and I grateful. Thank you for writing.
brieann.rn@gmail.com says
Thank you. God bless you.
Laura Zempel says
Lovely post, just want to clarify your first comments. People often think that Palliative care always means Hospice. I spend everyday teaching people , like you stated, that Hospice is one form of Palliative care. Some Palliative care is for those patients who are receiving curative aggressive treatments, but may need assistance with symptom management , emotional, practical, or spiritual support. It is a large umbrella of care that supports patients through a continuum of care, no matter the treatment goals. The pts must have either a serious or chronic illness, and would benefit from this level of care.
For those with aggressive tx goals, Palliative care is provided via a Home Health agency that offers a Palliative program. If the goal of care is comfort focused, than the care is provided via a Hospice agency,
Laura Zempel RN, MSW, CHPN
brieann.rn@gmail.com says
Thank you for sharing.
Martiza Montag says
I’ve been a nurse for only 6 months, I have always treated my patients as I would my family members. I have also learned that sometimes all they want is you to hold their hand. I look forward to going into palliative care in the future. I look forward to reading your blog.
brieann.rn@gmail.com says
Thank you. Best wishes to you!
Ruth pope johnston says
Unfortunately under our current healthcare and hospital model, if one is under hospice care in the home environment, most hospitals will not agree to readmit hospice patients to the hospital even if the cause for re admission is unrelated to their chronic life limiting diagnosis. The truth is hospitals feel that they will not be reimbursed for the re admission. I recently had a close friend who fell through the cracks in just this situation which was tragic. I felt this needed to be clarified in your article which was lovely. It should work the way you outlined, but the truth is it usually does not.
brieann.rn@gmail.com says
Thank you for commenting. Apparently Medicare reimbursement must have changed in the past few years. It still allowed payment for unrelated diagnoses when I worked in hospice. Thanks again.
Am says
It still does. I have a hospice that is inpatient now for something unrelated. It’s not “not allowed” but sometimes the billing has to be submitted a few different ways to get it paid for appropriately.
Roxane Monico says
I loved your article because I totally “get it”. I am a nurse in a long-term care facility for the elderly and it is one of the most rewarding aspects of my job. Good article! It is imperative that we educate our professional and non-professional community regarding hospice.
Crystal says
Thank you so much for this post. I am an ER nurse. I get so frustrated when physicians and other nurses remark “well, they are a DNR”. It doesn’t mean you don’t treat what is treatable. DNR doesn’t mean no treatment. To many health professionals do not know the true meaning of hospice or understand DNR.
Kathy Nolan says
Thanks for saying things that everyone in this country needs to hear. It is so hard for some patients and families to get past the “I am giving up if I go into hospice” feelings. It’s all about timing. As an ICU nurse I have seen some patients and families travel that road with common sense,love and dignity while others are train wrecks. If I ever have to travel that road I hope I can do it with dignity. It takes courage and lots of love!
brieann.rn@gmail.com says
Thank you for commenting.
Cindy Quiocho says
I’m a retired RN from October of last year. I am already volunteering at a local hospital. Then my mother passed away 2 months ago. I got interested in volunteering once a week at the hospital’s hospice facility to give back blessings I received to people who were near or at their road’s end. The orientation was brief but I just felt I did not have enough to give of myself emotionally, the way I had planned to. I think I still need time to heal. I read your article and the introductory paragraph was speaking out to me. Thank you for writing exactly how I feel about hospice.
brieann.rn@gmail.com says
Thank you so much. God bless you.