Dear Barbara, Can you write about hospice care and the role of the hospice nurse/hospice team in long term care facilities?

The basic premise of hospice is to provide end of life care in the home. Because Assisted Living and/or Nursing Facilities are home for some people, it is appropriate that hospice care be available for residents in these facilities. The issue then becomes is there an overlap of services such as nursing care, bathing, or communication with a physician? Some facilities think there is an overlap and feel they can provide end of life care without the assistance of an outside (hospice) source. Other facilities create their own “hospice” team and provide their own kind of end of life assistance. Still other nursing facilities welcome the expertise of a hospice from outside their facility.

How can Hospice and Nursing Facilities work well together?

I think there are as many ways for a hospice to work with a nursing facility as there are hospices and facilities (all within medicare guidelines of course), but I will tell you what I consider the ideal relationship.

* A hospice team (RN, LPN, SW, HHA, Chaplain, & Volunteers) is assigned to an individual facility. Only that team works in their specific facility. You want everyone in the facility to know, recognize, and understand the hospice team. The entire nursing facility staff (right down to the receptionist) attends an inservice by that hospice team.

* Several educational sessions need to take place in order to clarify not only the role of hospice for the patient, family, attending physician, and facility, but also to provide end of life knowledge (pain management, comfort care, signs of approaching death, and nutritional guidelines) to these same people. Nursing facility regulations are basically in opposition to end of life care. I know, it makes no sense to me either, but since the government is focused on avoiding death and concentrates instead upon rehabilitation, hospice care in a nursing facility often walks a thin line. For this reason developing a good knowledge base and relationship is paramount to a smooth working relationship between hospice and facility.

What is the role of Hospice in a Nursing Facility?

To provide the same care as if the patient were in their home--which they now are. In taking care of the patient the hospice team’s role is to assess physical, emotional, and spiritual needs. The only difference at a facility vs at home is the hospice team is working through facility protocol and with the support and understanding of the facility staff. Support and understanding is paramount for a good working relationship which is why inservice meetings and the same team is so important.

* Bathing can now be done by the hospice staff. Some facilities are uncomfortable with this even though it helps the work load of their staff.  * The use of volunteers for the patient depends upon the patient’s closeness to death.

* Interaction with the attending physician must be done through the facility nursing staff since the facility has license and regulations to adhere to and the hospice nurse is not part of the nursing facility staff. This is a “sticky” area and another reason the hospice team remains the same so a bond and trust can be established and maintained.

* The role of hospice is to support and guide the patient’s family, no matter where the family is located. Family and significant others are always part of hospice care. The only difference in a home or a facility is convenience of family location. The hospice team must seek out and make contact with the family after each visit to the patient in a facility. A person to person visit is preferable as it is more comforting and supportive than a phone call. If family is not in the area of course find a primary family member to be the contact and call after each visit to give an update and assess if there are any supportive issues that need to be addressed.

* Nursing Facility staff in many cases has become the patient’s family and they need guidance and emotional support as any family member would. This awareness is key in the bond and relationship established between the facility staff and the hospice team.

Medicare has micromanaged hospice services to such a degree that I realize my ideal may be impossible to reach today. So sad!

Something More About... Hospice Care in Nursing Facilities

Hospice marketing teams use our dvd/kit NEW RULES for End of Life Care to show Assisted Living Facilities how they care for their patients. It is a training tool and also a calling card to say, "This is how we will take care of your dying".