Empowering caregivers, families, and nurses in end-of-life care
Author: Peter Abraham, BSN, RN
Peter Abraham is a seasoned nurse committed to supporting nurses, caregivers, families, and patients in their learning, growth, and well-being journey. His extensive nursing career includes practical experience as a cardiac telemetry nurse in a dynamic cardiology unit at a Magnet-awarded teaching hospital. Additionally, Peter has served as a second-shift RN supervisor, managing an entire building in a Skilled Nursing Facility/Long-Term Care (SNF/LTC) setting with 151 residents. Notably, during the initial wave of COVID-19, the facility achieved an impressive near-100% recovery rate before the completion of Operation Warp Speed.
Peter's nursing career also extends to rural home hospice care. As a visiting hospice registered nurse case manager, he provides compassionate care to patients in various settings, including private homes, personal care homes, assisted living facilities, skilled nursing facilities, and hospitals. His dedication to compassionate care led to the establishment of the Peter Abraham Wound Care Scholarship, which offers education in wound care. This scholarship, associated with the theme of "Wound Care: Enhancing Healthcare for the Aging Population," underscores Peter's commitment to improving care for those in need.
Caring for a loved one with dementia can be challenging. This article provides insights into understanding dementia, its stages, and practical tips for caregivers. Learn about the FAST Scale, validation therapy, and when hospice care might be appropriate to ensure compassionate and effective support.
There are several things that go on behind the scenes when you or your loved one is admitted to a hospice provider. Some of them you may never see because it doesn’t impact the care provided and received. Others like the hospice benefit periods may only come out of the woodwork (so to write) at certain times and can either cause joy or distress depending on one’s point of view.
The goal of this article is to keep it simple and smile (my version of the K.I.S.S. principal) understanding of hospice benefit periods. When a person is first admitted to a hospice provider (having never been on hospice), they start off (behind the scenes) in benefit period number one. This is the first half (90-days/3-months) of the estimated six-months or less to live. Benefit period number two is the second half (3 more months/90-days). And since a terminal illness doesn’t come with guarantees that one will pass in six months or less, Medicare allows for (with fine print through the entire journey) an unlimited number of sixty-day (two months at a time) benefit periods.
This article is meant to help families and new hospice staff understand the four hospice care levels. According to Medicare guidelines, several levels of care govern hospice services in the United States of America, whether the patient uses Medicare or not.
There are observation and interviewing skills you can develop which will help you learn:
What could cause the current change in condition
Determining if a patient is having terminal restlessness
Determining if your patient is within two weeks or less of life to live
Knowing where your patient is in the dying process
While this article is primarily meant for new nurses, what I’m sharing is also valuable for family members and loved ones. Anyone with patience and love toward the person being observed and interviewed can hone and develop these skills.
As nurses, when we see an acute change of condition, part of what we should be doing in our assessment is determining if there are reversible or treatable elements that are causing the change. In RN school, Dr. Dagen taught the students about using the D.O.G. mnemonic to help us remember that if a patient has an acute change of condition to check whether there were new medications the patient is taking, their O2 saturation level and their glucose level.
I would further add that as a hospice nurse dealing with mainly geriatric patients that if there is an altered level of consciousness (LOC)/personality change, to also consider the patient may have an infection. For any of you dealing with geriatric patients add “I” for infection, hence “D.O.G.I.” While this mnemonic is typically used for acute changes of level of consciousness, the thought process behind it can be used for other acute change of patient condition as well.
Faith and religion in the workplace: Yes, faith has a place in work, and when utilized to direct how one works and interacts with one's patients and families, it can result in a blessing that does not disrespect others.
This article came to be partly a response to one of my favorite YouTube nursing channels, where Nurse Katherine provides educational videos for new and experienced nurses. Her most recent episode at https://www.youtube.com/watch?v=N_lE9O1I3LQ asks the valid question relating to the place of “Religion, Beliefs, and the practice of Medicine | should & can they be combined?”
The dying process involves physical and emotional changes as the body shuts down. As the heart weakens, circulation slows, leading to cold hands and feet, pale skin, and drowsiness. Breathing becomes irregular and shallow. The patient may experience delirium or visions. Providing comfort through pain management, emotional support, and spiritual care is crucial.
When a loved one nears the end of life, it’s natural to worry about their nutrition and hydration. This article explains why they may not need food or water and how you can provide comfort during this time.
Hospice care is a vital service that provides compassionate and specialized support to individuals with life-limiting illnesses, particularly when they receive care at home. Understanding what home hospice covers is essential for patients and their families to ensure comprehensive and personalized end-of-life care. This article aims to shed light on the various aspects of home hospice care, including medications, durable medical equipment, staffing support, and expertise in managing the natural dying process. By delving into these details, individuals can make informed decisions and better comprehend the valuable assistance hospice care provides during this sensitive time.
Falls among the elderly can have severe consequences, including hip fractures, which can be life-threatening. As an experienced hospice registered nurse case manager, I understand the importance of fall prevention, especially in private homes, personal care homes, and assisted living facilities. This article aims to provide practical tips for reducing falls in these settings by following the nursing process: assessment, diagnosis, planning, implementation, and evaluation.
GIP, or General Inpatient Hospice, is an often misunderstood aspect of hospice care. Both hospital staff and families sometimes have misconceptions about GIP. Families may assume it's readily available upon request, while hospital professionals may believe it allows patients to remain in the hospital indefinitely, even when death is weeks away. This article will clarify the basics of GIP for hospice, including eligibility requirements, doctor's orders, care plans, documentation, and education. We'll conclude with two real-life cases to illustrate these points.
A hospice house is a peaceful, home-like residence where terminally ill people receive short-term hospice care. It is designed to provide a setting as close to home as possible, allowing for more freedom than a traditional facility. Hospice houses are typically run by not-for-profit organizations and are financed by donations, making them more economical for families who cannot afford skilled nursing facilities. Unlike inpatient hospice units (IPUs), hospice houses work with several hospice providers, allowing families to choose the provider that best suits their needs. They also follow a more flexible visitation policy, allowing families to visit 24x7 without appointments.
One of the hardest lessons to learn as a nurse, in my experience and opinion, is the psychosocial skills necessary to help patients and their families work towards their healthcare goals. These skills are applicable to every field. While I, myself, am still growing as a registered nurse (heading towards my 5th year at the time of writing this article), I would like to share with you some of the lessons learned. These lessons are based on real-life cases where I will present the scenario, what I did that worked, and what I internally thought of opposite scenarios.
Hemoptysis, or coughing up blood, can be a distressing symptom for patients at the end of their life journey. As a hospice nurse, your expertise in managing this symptom is crucial in ensuring a peaceful and comfortable experience for your patients and their families.
Hospice care is a specialized form of medical care for individuals with a life expectancy of six months or less, focusing on comfort, quality of life, and symptom management. It affirms life and recognizes dying as a natural process, neither hastening nor postponing death. The aim of hospice is to help patients live as fully and comfortably as possible, providing comprehensive support for both the patient and their family. This unique approach to care is exemplified by the stories of patients with terminal cancer who, with the help of hospice, were able to fulfill their final wishes, such as feeling the sun on their face or visiting the beach one last time. These experiences highlight that hospice is not just about dying, but about making the most of the time that remains, finding joy, and creating meaningful moments.
I don’t know about you, but every time I see a patient and their family for the first time and take their vitals as part of the nursing assessment, either after each vital or at the end of the vital checks, I’m asked something to the effect of “is that good?”
As you, my friendly readers, bloom as hospice nurses, you will learn that the vital sign portion of the assessment is just a smidge of the entire assessment as to whether someone is approaching the end of life, going through reversible or terminal restlessness, or just having a difficult day. Let me share how I educate families that get hyper-focused on vitals.
Pain is a subjective sensation that can affect a person’s physical, emotional, and spiritual well-being. While pain can be measured objectively by using vital signs such as temperature, pulse, blood pressure, and respiration count, these indicators may not reflect the true intensity of pain that a person is experiencing. This is especially true for non-verbal patients, who cannot communicate their pain verbally. Non-verbal patients may include those with advanced dementia, terminal illness, or other conditions that impair their speech. In this article, I will discuss the importance of assessing pain in non-verbal patients, the tools and methods that can be used to do so, and the benefits of providing adequate pain relief for these patients.
Personal stories from the frontlines of Covid-19 in a nursing home, highlighting the bravery of heroes and the harsh realities faced by residents and staff.
When I first started working in the field of hospice, my clinical manager told me (I’m paraphrasing), one day you will be able to walk into the room, and without getting a single vital sign, just by visual observation, be able to tell that the person is dying or will be shortly dying. That was about three years ago. Today, it’s almost chilling for me (as it is both a blessing and tremendous responsibility) to be able to share she told the truth, and that over time — if you give yourself patience and grace and take the time to listen, observe, and remember — you too will learn how to tell when someone is close to or otherwise is dying.
Please allow me to share some of my insight as to how I know a person has less than a month left to live, and often far less. First off, let’s go into the important discussion you should have with the family, friends, and the patient themselves that provides an overall background to the prognosis. That discussion should be centered around what types of decline (downward, negative) changes have been taking place in the patient’s life over the last six months making note as to whether the decline is minor, medium, or major and the frequency (once a month, once a week, etc.) of those changes.
You are in with a patient with whom you believe will benefit from a treatment/medication. You call the provider who either goes with the recommendation you made as part of the SBAR (situation, background, assessment, nursing recommendation) or otherwise adjusted it to better fit the situation.
Most EMR (electronic medical record systems) now requires you to enter a doctor (provider) order. For visiting staff, most EMR systems will send an electronic communication to the doctor to “sign” the verbal order over the next 24 hours (some systems, the next business day).
Can you imagine how many orders the provider must sign in a day? How do you protect your patient and your nursing license in the written documentation of the doctor’s order you enter into whatever system you are using?
Your dying patient has lost their gag reflex as part of the dying process. One of the questions I implore you to ask yourself is what’s the safest route to administer liquid medications? Well, before even going to answer this question, unless contraindicated, make sure the patient’s head of the bed is at least at a 30 to 45-degree angle (I prefer the latter).
The buccal route is the safest route to administer liquid medications at the end of life in my experience. In practice, I strongly encourage you as well as the families we mutually teach to give any liquid medications on the side of the mouth least likely to have spillage — this depends on the position of the patient — and slowly over time giving the medication in 0.25 ml increments allowing for the absorption of the medication switching cheeks as applicable.
Navigating the final days of a loved one's life can be a challenging and emotional journey. One of the signs that can be observed during this time is known as terminal restlessness. As someone deeply rooted in hospice care, I have witnessed various manifestations of this restlessness. Understanding its types, causes, and management strategies is crucial for providing compassionate end-of-life care. This article aims to illuminate the different kinds of terminal restlessness, identify reversible causes, and discuss effective management techniques. By equipping caregivers, families, and healthcare professionals with this knowledge, we can ensure that terminally ill individuals experience comfort and dignity in their final days.
People often say to me, "It must be challenging to work in hospice." Unfortunately, due to HIPAA regulations, I cannot share photos of the events that occur. However, let me share a poignant moment from today—a dying individual's final wish was to feel the warmth of the sun on their face one last time. And we made that wish come true. This seemingly simple gesture held immense significance for both the patient and their family.
One of the main challenges of new nurses is time management. In a hospital or nursing home setting, you often have coworkers to rescue you in a pinch in case you are overwhelmed; on top of having nearby coworkers, most orientation programs, as well as nursing schools, focus on time management skills in a facility setting. Yet what about time management as a visiting nurse — in home health or home hospice or both?
Let me share with you my wisdom and experience in time management in the field of a visiting nurses to hopefully help you have more time for life compared to work — a better work-life balance.
