What does a workday look like for a visiting hospice nurse RN Case Manager? The answers will be different based on a combination of the personality of the hospice nurse (i.e., planner vs. spontaneous and those in between). Whether one works in an inpatient unit (IPU), sees patients only at one or more facilities, or has a mixture of facility and home patients, I can only glimpse a day in my life as a hospice nurse.
My Myers-Briggs personality type is INFJ, as confirmed by a masters-trained counselor. I am an over-compulsive planner, often having several plans, including backups, at any one time with the understanding all of the plans may need to be thrashed, and then comes the MacGyver moments. I serve mostly rural patients, and my caseload can vary from 50% home patients and 50% facility patients (the current situation in May 2023) to 25% home patients and the rest facility patients. Like my home patients, most facility patients are spread out in the county where I work vs. just one or two facilities.
Let’s review some background, such as the planning involved for the week, the types of visits that occur during any given day of the week, the visit itself, and what a day might look like when putting that all together.
Planning
Since I am an over-compulsive planner, there’s the rough draft for the week ahead before any day starts. This starts on a Sunday when I open my recertification journal, which I keep for all living patients, to update the changes from the previous week and review the overall velocity of changes in condition. This helps me to be aware of those patients approaching EOL (less than two to three weeks of life) status, as well as those who may have issues with recertification. If recertifications are due this coming week, I will create one draft recertification note for each patient (this can be zero to four for any given week). Those drafts help save tremendous time during the visit, allowing me to document all visits (except for admissions).
Lastly, I will look at where everyone lives to one another, and considering the acuity of each patient and their needs and where everyone lives, map out the potential route for each day, creating a framework of visits for the five workdays ahead. I do so knowing in advance there is a potential for this framework to change drastically; yet, by being so prepared, when changes happen, I can typically easily determine whom I can fit where and what visits can be moved or canceled based on patient needs.
On any given day, I may be seeing imminent patients such that they can die at any moment. If they are in a facility with RNs who can pronounce, I try to see them early in the day as all recommendations are typically in place by then for them to be kept comfortable, and anything now is fine-tuning. For imminent home patients, unless they have specific needs that require them to be seen earlier, I try to see them later in the day so that I’m not bouncing back and forth in case they die during my shift when I’m asked to go back to their location to pronounce the patient.
Visit Types
During any given day, a case manager like me may have routine (scheduled) visits and other categories of visits within a given day and week. There are weeks (sometimes several in a row) where all I have are routine visits to make or routine visits and an IDG meeting. There are weeks where I might have one admission, one-to-several EOL visits, one-to-several recertification for eligibility visits, one-to-several routine visits, and so on.
ADMISSION: The start of care (SOC) visit involves creating the framework of “why hospice, why now?” to establish initial eligibility. There is the onsite portion where the patient is assessed, and the education preparing the patient, family, and caregivers for a “good death” for the patient starts. The onsite portion of the admission takes 45 to 90 minutes, and then there’s the off-site charting to complete the admission; this portion can take anywhere from 90 minutes to three hours, depending on the case’s complexity. Even with agencies with dedicated admission staff, case managers like me are often asked to help with admissions.
DEATH: A death visit occurs within the workday either because the patient ceased to breathe (CTB) while I was present during the visit (each year, this happens less than or equal to 15% of the time), or I was notified to the head to the visit. The death visit involves assessing the patient to ensure they are dead — auscultate (listen) for lack of heartbeat for 90 seconds, lack of carotid pulse for 90 seconds, lack of breathing during this time (3 minutes); recording the time of death; filling the time of death blocks on the death certificate including my signature, nursing license, and that the coroner was contacted; calling the coroner and reviewing the case with them for permission to release the body. Then, there is a call to the patient’s attending doctor, who will complete most of the death certificate, and the funeral home, with family permission, lets the funeral home know to come after a particular time if the family is expecting to see the body before pick up. There’s the offer and performance of postmortem care to clean and dress the body for transport from the location of death to the funeral home (this is not the final dressing of clothing; just for transport). The death visit typically takes a minimum of 30 minutes but can go longer depending on the needs of the family, and in those rare instances, the coroner must come out to investigate a death.
DISCHARGE: Discharges occur for failure to decline when the patient is determined not to be in a terminal state. These visits typically mirror the routine noted below except for educating the family and patient about what’s next, such as home health. Most of the time, these visits are 30 minutes long.
EOL: There may be a different designation for these types of visits based on the hospice agency, but EOL visits for the agency I work with mean the patient has an expected lifespan of two to three weeks or less. Home patients on EOL status are seen in person by a nurse seven days per week without regard to holidays; this includes patients at personal care homes or other facilities that do not have RNs available within the facility. At a skilled facility, in-person visits are made Monday through Friday inclusive, except for holidays; for holidays and weekends, a triage staff member calls the RN supervisor/Unit manager asking for status. If a visit is needed, one is made. EOL Visits include ensuring there are enough medications to last, including anticipating spikes of use due to potential crises; education as to what to expect, such as what the family and caregivers will see in the last 36 to 48 hours of life; reinforcing calling hospice 24×7; education as to what the death visit looks like and what to expect. Patient assessment includes identifying the stage of dying: transition vs. actively dying, as well as substages such as the “rally.” These visits tend to run 60 minutes minimum and can take closer to 120 minutes if the family and caregivers have many questions.
IDG: Every hospice provider must have an interdisciplinary meeting (some call it IDG and others IDT) to discuss new admissions, recertifications for continued eligibility, discharges, revocations, etc. For some providers, this is an all-day affair, and for others, it takes several hours. The latter is where I work, where an IDG meeting can run 2.5 to 4 hours. And yes, we are expected to meet the needs of our patients. The actual time for IDG varies by census (number of patients on service).
POST ADMISSION: The second visit after an admission (start of care) that typically happens within 24-to-48 hours after the admission visit. These visits can be as extended as the admission visit as they involve going over the comfort medications (which may or may not have been present at the time of admission), symptom management, including any new issues or concerns, and reinforcement of the hospice philosophy and teaching about a “good death.” Since it is often very emotional for the patient and family to be in hospice, part of the visit includes going over “Why hospice, why now?” with the patient and family reviewing expectations and doing reality checks when expectations may not be realistic. These visits run 45 minutes to 90 minutes, with 60–to-90 minutes being the most common time commitment.
PRN: As-needed (PRN) visits occur when there is a change of condition reported by the patient, the family, a caregiver, or staff at a facility. Some PRN visits are for falls without injury, often the simplest, taking 30 minutes. Most of the time, a PRN visit is due to a crisis, which usually means 60 minutes or more as there’s the crisis resolution, debriefing to determine if the crisis was avoidable, and education on avoidance and future management if unavoidable. PRN visits can be reduced with proper planning and education, such as after-hours visits. There will still be falls, and specific disease processes, such as most types of cancer, will involve a higher rate of PRN visits than other types.
RECERT: Recertification for continued eligibility for hospice services. As a hospice RN Case Manager, I must document why the patient is still eligible (or not) to receive hospice services according to Medicare guidelines. Before developing a system to allow recertification visits to be exceptionally smooth, these visits used to take 60 to 90 minutes. However, by updating an eligibility journal weekly with noted declines (downward changes of condition) and then the Sunday before the recertification visit, writing up a draft document of the rectification, most recert visits take the same type of a ROUTINE visit plus just a few minutes extra if the patient is at home as I enjoy involving the family (and patient when feasible) in reviewing the final document.
ROUTINE: These are your “scheduled” visits that, for some patients, occur twice a week, others three times a week, and for some weekly. These visits aim to provide ongoing education to prepare the patient and family/caregivers for a “good death.” They also ensure medications are in place, symptoms are managed, refills are requested, and so on. These visits can run 30 to 60 minutes, depending on the patient’s and family’s needs.
Each of the above visits has its own “look,” so to write, but as each nurse has their personality and flare, there will be a common presentation for a visit.
The Visit
The “hospice” visit takes place wherever the patient lives. This can be in a private home or a facility (personal care, assisted living, nursing home, skilled nursing). The type of location determines how the visit itself starts. I start with the facility caregiver staff to check for any needs and changes in condition, including any medication changes. Suppose the location is a personal home, depending on the patient’s location within the house. In that case, I try to meet with the family/caregivers first to review any concerns, chief complaints, and changes of condition before seeing the patient in a home setting; the patient may be in the same area as the family and caregivers, so in that case, it leads to how I start with the patient.
When I see the patient, especially the first time, based on body language, I will approach their level (if at the bedside, this means kneeling or a chair) and take their hand, or I might put my hand on their shoulder. I soak everything in visually. Their complexion, the temperature of their skin, their ability to look me in the eye and track me as I approach them, their radial pulse (regular, irregular, weak, thready) as I lightly touch their wrist, if they are in pain via the PAIN AD scale, if they are short of breath as evidenced by their breathing rate and pattern. All of this is within seconds to a few minutes, based on the case’s complexity.
Then comes the actual physical assessment where vitals are taken, if applicable, the skin assessed, et al. I like the “sandwich” approach to visits where the “mechanical” (vitals and documentation) are sandwiched between a compassionate and caring entrance and conversation and education. So, once the physical assessment is complete, I will start documenting and educating about what to expect next. If applicable, I put the computer tablet aside to provide active listening and support as part of the education and encouragement before completing the documentation at the bedside, except for admission visits whose documentation is completed at home or the office.
A Typical Week Day by Day
Now that you have an idea of the planning that goes on to prepare for the week, the types of visits, and what an actual visit might look like, let’s go over a typical day in the life of a hospice nurse. Since days can vary, let me go over the week of Monday, May 29 through Friday, June 2, 2023:
Monday, 5/29 — Memorial Day holiday where I volunteered (though paid) to see three patients: a home patient on end of life who stated “two days” and did die two days later a patient at a facility who has four to six weeks to live, and another home patient with cancer who lives alone where we manage his pill planner. I left the house at approximately 7:30 AM and did not get home until after 1:00 PM, where I then worked on IDG notes because Thursday, 6/1, was IDG from 10:00 AM until it was over. The EOL visit ran around 2 hours, the facility visit went about an hour, and the other home patient took about 1.5 hours, including a suicide assessment, as the patient used words that would trigger such an assessment, for which I was thankful was negative. As this is IDG week, Monday through Wednesday, I will write IDG notes for the patients seen that day so that by the end of Wednesday, all IDG notes are complete.
Tuesday, 5/30 — While some weeks go completely according to plan regarding the patients to be seen daily, being a part of a healthcare team involves teamwork. As I was out in the field, my manager reached out to me concerning a patient of another nurse who happened to be on PTO and was going through a profound change of condition; would I be able to see them? Calls like this are not daily but can occur several times per month, if not per quarter. I’ve found that having a framework for the week and knowing the needs of my patients and families allow me to respond to these calls professionally and in a supportive way.
There was a day with six visits (I was currently on visit number three of the six when the call came), with the last visit being an EOL visit (as mentioned above), where I knew the family would need approximately two hours of my time at a minimum. This day was a combination of home and facility patients (a home, a facility 1 for one patient, another facility for two patients, a home, a home).
My next patient was within walking distance of the 3rd, and my fifth (before the EOL) was a 30-minute drive, about one hour anticipated onsite, then a 45-minute drive to the patient on EOL. Knowing that my 5th patient (the one with a 1 hour 15-minute drive time between the others) has their medication refills up to date and symptoms well managed allowed me to ask my manager for a moment, to call that particular patient and ask if they would be ok with only seeing me on Friday, 6/2 for which the patient responded yes; that allowed me to tell my boss yes to put that person on my schedule.
PRN visits are always a minimum of 60 minutes, and this one was no exception as this facility patient (~30-minute drive from the fourth visit) required a call to the PCP to adjust medications, update the appropriate facility staff, and reconcile the medications between the facility and hospice medication records. As the patient declined more frequently, the visit frequency increased. Then, off to my patient at the end of life. That visit ended my day a little after ten hours from the start of work (some days are closer to 8-hours, and some days are much longer).
Wednesday, 5/31 — Wednesdays are typically lighter days for me given that most patients (those who have greater than two to three weeks to live) are on a two visits per-week schedule (Monday/Thursday or Tuesday/Friday) with my Wednesday patients either being those that are just once a week, three times a week (Monday, Wednesday, Friday) or daily visits due to being on end-of-life. Yet, this Wednesday was full, with six visits, as our team was all pitching in to cover for one of our nurses who had a personal emergency where they would be out for several days.
The last visit was for my glioblastoma patient, who died later that day. I believe that part of providing compassionate care as a hospice nurse is that presence matters as much as education, so I always allow for more time for EOL visits. Sometimes the family needs it, and sometimes they don’t. The family needed it this day, as I could tell the patient was in their last 36 hours or less. Before the end of the day, whether I could physically be present for IDG or not, I needed to complete my IDG notes and email the IDG team a summary for each patient.
Thursday, 6/01 — A mixture of home and facility patients. I emailed my manager, offering to see the patient I saw on Tuesday for the PRN visit, as the nurse who saw her on Wednesday received an order for new meds, and reports were coming in that the patient was still not doing well. While I was in the midst of my first visit, my manager called me to see if I could pronounce the patient I asked to see again. We are not EMS, so I finished my first visit without rushing and then went to pronounce the patient. My patient with glioblastoma died Wednesday night (two days after they said “two days”), so there was not an EOL visit on my schedule. While that did mean getting home relatively timely, my boss reached out to me asking if I would be open to making an admission for the nurse who is off, which would allow one of our other nurses to be a runner. Personally, teamwork makes the dream work, and I try to find ways to participate in a team, so the answer is yes.
Friday, 06/02 — Home and facility patients with one admission — a patient with esophageal cancer at the local facility. I head to the office before heading to the first patient, one at home; I text the POA for the new admission an ETA in case they want to be present. They respond while I’m with my first patient, who lives with two friends, and based on the text, I check with them to see if I can call them on my way to the admission. Once I’m on my way to that admission (2nd visit), I call the POA, and we go over what that visit will look like from a bird’s eye view; they ask that we don’t talk about hospice or death until later this month when the patient gets their last CT scan as the patient — who is not seeking further treatment — wants to know if the cancer is terminal vs. possibly living longer than six months.
Since human beings are not the sum of clinical paperwork, you don’t know what to expect when you admit a patient. Will they die before you, and will you pronounce (or notify the appropriate staff) during the admission itself? Will you be putting them immediately on EOL (less than two weeks to live) status upon admission, whether you have to call management to ask why we are admitting them (because you don’t see them as terminal), or even what type of case (more straightforward to manage to harder to manage — based on symptoms, facility conditions, etc.)
Thankfully, while the patient is appropriate for hospice, they are not in crisis and crashing at the time of admission. Part of any admission involving cancer is knowing the most likely areas of cancer spread (Mets) and what medications can cause serious problems (i.e., most cancers are subject to increased risk of internal bleeding, but some even more so — and for esophageal cancer, avoid NSAIDS). For the spread, esophageal cancer can go to the lungs and liver, so pay more attention to lung sounds as well as abdominal girth (and, if available, INR and Albumen lab values). In this case, muffled and weak heart sounds without presentation of Beck’s triad show a level of lung involvement and so noted. Then, we will go off to the rest of the visits for the day, ending up at home to complete the admission.
This week, there were a little over 16 hours of overtime, not including the 8 hours of holiday pay, but there are many weeks where it is a 40-hour week. Every day and every week are different.
Most days involve several layers of critical thinking, from the best ways to manage symptoms based on the patient’s needs — always thinking least invasive to most invasive, most comfortable to least, easiest for the caregivers to manage, etc., to the psychosocial. The latter often involves contemplating (sometimes jiffy on the spot) ways to communicate information that will cause the least distress and the most comfort in an honest way.
Conclusion
As a hospice nurse, my workdays blend meticulous planning, compassionate care, and adaptability. Each week, I carefully plan my visits, considering the needs of my patients, the acuity of their conditions, and the distances between their locations. My days are filled with various visits, including routine visits, admissions, end-of-life visits, and more. I approach each visit empathetically and professionally, ensuring the patient’s needs and their families are supported.
In a typical week, my schedule can vary significantly. For instance, on Memorial Day, I volunteered to see three patients, including a home patient at the end of life, a patient at a facility, and another home patient with cancer. Each visit required a different level of care and attention, reflecting the diverse needs of my patients. Additionally, teamwork is crucial in my role, as I may be called upon to see a patient outside of my planned schedule due to a change in their condition. This flexibility and responsiveness are essential to my work, allowing me to provide the best care to those in need.
Throughout the week, I engage in various visits, from routine check-ins to end-of-life assessments. Each visit is tailored to the patient’s specific needs, whether it involves medication management, symptom monitoring, or providing emotional support to the patient and their family. I approach each visit compassionately, ensuring the patient feels heard, understood, and cared for.
In conclusion, my role as a hospice nurse is multifaceted, requiring a combination of careful planning, clinical expertise, and, above all, empathy and compassion. Each day presents unique challenges and opportunities to make a meaningful difference in the lives of my patients and their families. Through dedication and a patient-centered approach, I strive to provide comfort and support to those navigating the end-of-life journey.
