Dear Barbara, My first day as a hospice nurse I watched some videos in the office then sat in the conference room for 4 days. I oriented in the field for two weeks with the DON. After that I got my 18 patient caseload. Even with help from my team I am drowning and miserable. 

We are in a rural area. My patients are a 30-120 minute commute. I have multiple patients declining and multiple patients with wounds, all of which would benefit from more frequent visits, which I physically can't do because I am already in overtime every week. My patients are suffering. When I relayed this to my supervisors, I was told that I would be expected to see even more, and needed to conduct admissions after seeing my patients, that everyone else is busy, etc. 

I haven't charted on my patients from this week. I am on mandatory on call. I worked all night and all day. I am now being sent an hour away to do an admission. Only my second solo admission even though I've never had my first solo admission questions answered. 

So, I have started to look for another job. I am crushed because I like my coworkers, patients, and this work. I am just crushed.

I’ve been getting too many stories of hospice care and practices like the one above; about hospice agencies that place emphasis on the number of visits per day and the number of patients per nurse, not on what is actually happening in the patient’s dying process. Emphasis that seems to put the patient and staff low on the list of priorities in running an agency. 

I appreciate the challenge of balancing patients, visits, admissions and the bottom line of dollars brought in and dollars spent BUT I am seeing that taking care of staff and patients is often being sacrificed to that bottom line.

If we don’t take care of our staff, physically, emotionally, and energetically, the hospice will lose its grounding, its purpose, its reputation, as well as its Medicare standing (I hope). A hospice that does not take care of its staff cannot take care of its patients and their families in a manner consistent with the original hospice philosophy.

What is the hospice standard of care that may not be written into the Medicare regulations? Let's consider the number of patients per staff, how often and long are visits, what do actual visits consist of, and the role of primary care nursing.

I haven’t looked at the regulations recently. I do know there is a lot of micromanaging going on in them BUT my concern is what outside of regulations are common sense patient practices in the end of life arena? As Fareed Zakaria would say, “Here is my take.”

Patient load: Depends on driving distance between patients. If all patients are in the same nursing home then we can see more than if they are in a rural community with driving distance between visits 30 or more minutes. I think it also depends on closeness to death. If a referral is months before death or dementia is the main diagnosis we can see more patients than if we have late referrals and the patient is days, even a week or so from death. Average patient load: 15 patients. If everyone “crashes” at once it is the agency’s responsibility to assist its primacy care nurse with additional help so she can spend the appropriate time with each family and not have it be her sacrifice in time to provide the good care necessary. This size patient load makes for about five visits a day, two in the morning and three in the afternoon. That allows for driving and charting time as well as a drive thru lunch.