is focused on symptom management, pain relief, emotional support, and spiritual care. It is a privilege to be a part of a patient's end-of-life journey, and as a new , you may feel overwhelmed, but you can make a difference in a patient's life. One of the essential skills you need to learn as a is to recognize when to increase the scheduled for a terminally ill patient under .

Understanding the Hospice Process

Before we dive into when to increase , let's the hospice process. Hospice care is a service for people with serious illnesses who choose not to get (or continue) treatment to cure or control their illness. Hospice aims to provide comfort and peace to help improve the quality of life for the patient and their family. Hospice care typically involves a team of healthcare professionals, including doctors, nurses, social workers, chaplains, and volunteers, who work together to address the physical, emotional, and spiritual needs of the patient and their family.

Factors to Consider

As a hospice nurse, it's important to consider several factors when determining if a patient requires an increase in scheduled visit frequency. Here are some factors to consider:

  • Symptom management: If a patient's symptoms are not being managed effectively, it may be necessary to increase visit frequency to adjust medication or implement other interventions. This may involve PRN visits as well as a modified schedule frequency for several days to several weeks.
  • Disease progression: If a patient's disease is progressing rapidly, it may be necessary to increase visit frequency to provide additional support and monitoring. If the changes are happening daily to several times per week, the patient may be at end-of-life.
  • : If a patient's primary caregiver is experiencing burnout, it may be necessary to increase visit frequency to provide additional support and .
  • Psychosocial needs: If a patient is experiencing emotional distress, , or depression, it may be necessary to increase visit frequency to provide additional support and counseling.
  • End-of-life care: As a patient approaches the end of their life, it may be necessary to increase visit frequency to provide comfort and support to the patient and their family. The gold standard for end-of-life visit frequency should be daily for patients at home, personal care, or assisted living.

In relation to the last area, end-of-life care, every single visit whether scheduled or PRN should involve your documenting either in a recertification journal, a visit journal, or even in the patient's narrative where appropriate your clinical judgement as to where the patient is at within their hospice journey. That is how long do you think they have before their last breath. This is an “in the moment” clinical judgement that no one will hold you to in terms of exact standards; but should help you have an idea of how often you need to put eyes on the patient as well as help you prepare the family for what may happen over the next several hours to several days to several weeks.

When to Consult with the Hospice Team

Always remember that you are a part of a hospice team. You may be alone in the field, but your medical director, supervisor, fellow nurses, and team members are a phone call or email away. Reach out to them if you are concerned about the scheduled visit frequency. This can include your asking for help for the patient to be seen more often by another nurse if your caseload is too high.

Scheduled Visit Guidelines to Consider

Brand new admissions where the patient's () is 30% or higher and whose caregivers or family reports monthly to every other month significant declines: see the patient at least twice a week until you've confirmed a three month to six months estimate of what may remain of the patient's lifespan.

If eligibility is questionable (i.e. they may be discharged for failure to decline) with patient and family agreement, back off visits to once a week to once every two-weeks with the understanding of the Medicare guideline for one visit every literal fourteen days.

For patients in the two-to-three-month window, at least twice a week visits. For those in the three weeks to six weeks window, three times a week visits; and for those with three weeks or less to live, daily visits with consideration of telephone calls to skilled facilities on the weekend vs in-person visits.

Conclusion

Caring for terminally ill patients under hospice care can be both challenging and rewarding. Knowing when to increase scheduled visit frequency is an important part of providing effective hospice care. By considering the factors listed above and being aware of the signs to look for, you can ensure that your patients receive the care and support they need during this challenging time. Remember, as a hospice nurse, you are part of a team of healthcare professionals who provide compassionate and comprehensive care to your patients and their families.

Resources

CMS Claims-based Quality Measure Development

Improving Your Agency with CMS Data: Quality Measures (HQRP) and PEPPER

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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