What does a workday look like for a visiting hospice nurse RN Case Manager? While 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) and whether one works in an inpatient unit (IPU) or sees patients only at one or more facilities or has a mixture of facility and home patients, I can only provide a glimpse of 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 of the facility patients are spread out in the county that I work vs being just one or two facilities.

Let's go over 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, then what a day might look like putting that all together.

Planning

Since I am an over compulsive planner, before any day starts, there's the rough draft for the week ahead. This starts on a Sunday where I open my recertification journal that I keep on all living patients to both update the changes from the previous week, and to review the overall velocity of changes of condition. This helps me to be aware of those patients approaching (less than two to three weeks of life) status as well as those who there may be issues with recertification. If there are recertifications 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) within the visit itself.

Lastly, I will look at where everyone lives in relation to one another, and considering the acuity of each patient, their needs, as well as 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, what visits can be moved or cancelled based on patient needs.

On any given day I may be seeing patients who are imminent such that they can die at any moment. If they are in a facility with RN's 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 home patients that are imminent, 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 where 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 a mixture of 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 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?” in terms of establishing 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 of time, 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 complexity of the case. Even with agencies that have 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 breath (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 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 letting the funeral home know to come after a certain time if the family is expecting to see the body prior to 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 on those rare instances the coroner must come out to investigate a death.
  • DISCHARGE: Discharges occur for failure to decline where the patient is determined not to be in a terminal state. These visits typically mirror a routine visit noted below except for education to the family and patient as to what's next such as home health. Most of the time these visits are 30 minutes.
  • EOL: There may be a different designation for these types of visits based on the , but EOL visits for the agency for whom I work 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 holiday; this includes patients at personal care homes or other facilities that do not have RN's 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 a status. If a visit is needed, one is made. EOL Visits include ensuring there is enough medications to last including anticipating spikes of use due to potential crisis; 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 “.” These visits tend to run 60-minutes minimum and can take closer to 120-minutes if the family and caregivers have a lot of 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, et al. For some providers, this is an all-day affair, and for others, several hours. The latter is the case where I work where an IDG meeting can run 2.5 to 4-hours. And yes, we are expected to see 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 long as the admission visit as it involves 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 for the patient to be on hospice, part of the visit includes going over “why hospice, why now?” with the patient and family and to review expectations and do 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 in terms of time commitment.
  • PRN: As needed (PRN) visits occur when there is a change of condition either reported by the patient, the family, a caregiver, or staff at a facility. Some PRN visits are for falls without injury; these are often the simplest, taking 30-minutes. Most of the time, a PRN visit is due to a crisis of some type; and that often means 60-minutes or more as there's the crisis resolution, debriefing to determine if the crisis was avoidable and the education on avoidance as well as future management if unavoidable. Like after-hour visits, PRN visits can be reduced with proper planning and education. There will still be falls, and certain disease processes, such as most types of cancer, will involve a higher rate of PRN visits than other types.
  • RECERT: Recertification for continued eligibility of whereas a hospice RN Case Manager, I must document according to Medicare guidelines why the patient is still eligible (or not) to receive . Prior to 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 ); and then the Sunday prior to 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 types a week, and for some weekly. The goals of these visits are ongoing education to prepare the patient and family/caregivers for a “good death.” These visits involve ensuring medications are in place, symptoms are being managed, refills are requested, and so on. These visits can run 30 to 60 minutes depending on the needs of the patient and family.

Each of the above visits have their own “look” so to write, but as each nurse has their own personality and flare, there will be a common presentation for the visit.

The Visit

The “hospice” visit takes place wherever the patient lives. This can be in a private home or a facility of some type (personal care, assisted living, nursing home, skilled nursing). The type of location determines how the visit itself starts. I start with the caregiver staff at facilities to check for any needs and including any changes of medications. If the location is a personal home, depending on the location of the patient within the home, I try to meet with the family/caregivers first to review any concerns, chief complaints, changes of condition before seeing the patient; in a home setting, the patient may be in the same area of 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 bedside this means kneeling or a chair) and I will 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 within seconds to a few minutes based on the complexity of the case.

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 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, what an actual visit might look like, let's go over a typical 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 did volunteer (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 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 come the end of Wednesday, all IDG notes are complete.

Tuesday, 5/30 — While some weeks go completely according to plan in terms of the patients to be seen each day, 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 going through a profound change of condition; would I be able to see them? Calls like this are not a daily thing but can occur several times per month if not per quarter. I've found that by having a framework for the week, and knowing the needs of my patients and families allow me to respond to these calls professionally in a supportive way.

Here was a day with six visits (I was currently in 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 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 (prior to the EOL) was a 30-minute drive, about one-hour anticipated onsite, then a 45-minute drive to the patient who is on EOL. Knowing that my 5th patient (the one with 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, to update the appropriate facility staff, and to reconcile the medications between the facility and hospice medication records. As the patient was having more frequent declines, the for the patient 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, six visits, as our team was all pitching in to cover for one of our nurses that had a personal emergency where they would be out for several days.

The last visit was my glioblastoma patient who did die later that day. It's my personal belief 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. This day, the family needed it as I could tell the patient was in their last 36-hours or less. Before the end of the day, whether I can physically be present for IDG or not, I needed to complete my IDG notes as well as 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 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 go pronounce the patient for whom 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 doing 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 as a team; so, the answer was yes.

Friday, 06/02 — Home and facility patients with one admission — a patient with esophageal cancer at 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 birds 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 — just 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 be dying before you and you will 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 might have to call management to ask why are we admitting them (because you don't see them as terminal), or even what type of case (easier 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/or crashing at 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 paying 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 shows a level of lung involvement and so noted. Then off to the rest of the visits for the day, ending up at home to complete the admission.

This week was a little over 16 hours of overtime not including the 8-hours holiday pay; but there are many weeks where it is a 40-hour week. Every day is different; every week is different.

Most days involve one to several layers of from the best ways to manage symptoms based on the needs of the patient — 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 a way that is honest.

Conclusion

As a hospice nurse, my workdays are a blend of 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 types of visits, including routine visits, admissions, end-of-life visits, and more. I approach each visit with empathy and professionalism, ensuring that the patient's needs are met 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 aspects of my work, allowing me to provide the best possible care to those in need.

Throughout the week, I engage in various types of visits, from routine check-ins to end-of-life assessments. Each visit is tailored to the specific needs of the patient, whether it involves medication management, symptom monitoring, or providing emotional support to the patient and their family. I approach each visit with a compassionate demeanor, ensuring that 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 . 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.

Resources

Understanding Hospice Care: Is it Too Early to Start Hospice?

What's the process of getting your loved one on hospice service?

Picking a hospice agency to provide hospice services

Medicare — Find and compare hospice providers

The Importance of Caregiver Journaling

Reporting Changes of Condition to Hospice

Eldercare Locator: a nationwide service that connects older Americans and their caregivers with trustworthy local support resources

As an Amazon Associate, I earn from qualifying purchases. The amount generated from these “qualifying purchases” helps to maintain this site.

My Aging Parent Needs Help!: 7 Step Guide to Caregiving with No Regrets, More Compassion, and Going from Overwhelmed to Organized [Includes Tips for Caregiver Burnout]

Take Back Your Life: A Caregiver's Guide to Finding Freedom in the Midst of Overwhelm

The Conscious Caregiver: A Mindful Approach to Caring for Your Loved One Without Losing Yourself

Dear Caregiver, It's Your Life Too: 71 Self-Care Tips To Manage Stress, Avoid Burnout And Find Joy Again While Caring For A Loved One

Everything Happens for a Reason: And Other Lies I've Loved

The Art of Dying

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying

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

As an Amazon Associate, I earn from qualifying purchases. The amount generated from these “qualifying purchases” helps to maintain this site.

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

Oh hi there 👋 It's nice to meet you.

Sign up to receive updates on new articles to your inbox.

The emails we will send you only deal with educational articles, not requests to buy a single thing! Read our privacy policy for more information.

Share your love