Why Hospice is Good

When I was growing up I had never heard of hospice. When I was in nursing school it was mentioned only briefly. I didn’t learn anything about hospice until I started my second real home care job. I learned a couple of important things:

  • This patient is definitely not getting better
  • Never call 911
  • Try not to talk about it

Unfortunately, I didn’t really have any direction and these were just things that I figured out on my own (obviously). After a few years the agency I was with decided they wanted to open their own hospice. This was great because they hired people to train the staff and all of a sudden I had an expert at my fingertips.

I volunteered for extra training and I had the opportunity to learn more about the attitude of hospice. Sheila was the instructor and I really liked her. I liked how genuine she was and I felt her passion when she was teaching me things. She tried to teach me how to talk less and listen more. It was a shock when she told me that, and I am still struggling with it.

I still didn’t have a great understanding of what hospice was and why it was so great, but I definitely had gained some insight from Sheila.

When I started teaching classes to home health aides for orientation and inservices, hospice was one of the topics. It was in these classes that I started to perfect my “Why I love hospice” speech. I know Sheila told me to stop giving speeches but this was a really good one.

What is hospice? Hospice is an insurance benefit. In order to be eligible to get unemployment, you have to qualify. In order to get disability, you have to qualify. Hospice is an insurance benefit, like other insurance benefits you have to qualify for the benefit. There has to be a doctor that “signs off” on your medical needs in order for you to receive the insurance benefit. In order to qualify for hospice you have to have a doctor sign a paper that says; if your disease runs its normal course your life expectancy is six months or less. You agree to stop receiving curative treatments and not use 911 or the emergency room for treatment. Hospice is a BENEFIT. You get medications, medical supplies, 24 hour nursing support, weekly home health aide hours, access to clergy, therapists and volunteers. There are people who will read to you, sing to you and paint with you. It is interdisciplinary. If you qualify for hospice, you qualify for all of the benefits associated with it. It does not mean that you are somehow hastening death, or happy with the impending death. This we cannot control. What can we control? Pain, comfort and dignity. When you deal with hospice, you are dealing with experts. Yes, experts in “end of life”, experts in death. What a blessing to have a group of professionals who are experts in dealing with all the issues at this crucial time. If you have a problem with your heart, you see a heart specialist. If you have a problem with your lungs, you see a lung specialist. That is all hospice is. Death speacialists. And we, as the caregivers, have an awesome responsibility to provide guidance and support during this terrible time. Because it is probably the family’s first experience with hospice, the family looks to the caregiver for reassurance and support. Don’t refuse to take a hospice case because it is “hard” or “sad”. Be honored that you are invited into this family’s life during this very difficult time.

I often get choked up when I give this speech, and I have given it many, many times. I truly believe that caring for a hospice patient is an gift. It is a gift to the patient, and it is a gift to the caregiver. A couple of weeks ago I was taking care of a patient who was recently admitted to hospice. After we were finished discussing their services I looked at the patient and said, “Do you want me to cut your nails?” The wife emphatically said, “YES!” I was surprised that she wouldn’t do it herself, and I had never cut another adult’s nails in my life, but I realized that I was being given an opportunity to really care for this patient. His nails were gross. When I was done, they looked great.

I come from a long line of strong-opinioned, strong-willed, somewhat pushy women. These days I mostly tell it like it is. I try to be totally honest with my patients without hurting their feelings.

I have always tried to be honest with my children. I have learned (from my mother) to answer all questions matter of factly and in a way that the child will best understand. In my almost 19 years as a parent I have answered questions about sex, babies, circumcision, masturbation, viagra, pregnancy, abortion, relationships, abuse, pride in one’s body, eating healthy, breast milk, child birth, cesarian sections, death, burial…you get my point.

Recently my 18 year old daughter told me an acquaintance of hers has had a reoccurrence of his cancer. She told me that he is on hospice. She asked me if he has a chance of being ok. I told her no. 

At the home care company where I work I have treated more hospice patients in the past 3 months than I have in the past three years. I learn something new from each patient.

One daughter told me that all she wants is to get to talk to her father before he passes. I made sure to share that with the nurses caring for the patient and they knew to wake the daughter if the patient was having a moment of lucidity.

A wife recently told me that her husband just wants to die. I made sure to share that with the nurses caring for the patient and they knew to give the maximum medications that can be safely administered as per the doctor’s orders.

A son shared with me that his mother needs to be in charge. I made sure to share that with the nurses caring for the patient  and they knew to check with the patient regarding all care needs and issues.

These, and many other, patients taught me that each life (and death) is different. I always ask the client or their family member, “What are your priorities for care?”. I also ask them to let me know if there is anything else I can help them with, or do anything else for them. Inevitably, I am given the same answer.

“Please make them better”.

If only I could.

Lessons I’ve Learned:

  1. It sucks, but death is a part life. 
  2. Take the services that are available to you. 
  3. Don’t be afraid of the truth. 

 

 

 

How to Make Your Patient Happy

 

I’ve been a people pleaser for a long time now. I’m not entirely sure when it all started. I distinctly remember being an annoying, pain in butt kid and teenager.

Whenever it began, it is a large part of the adult me. In my yearbook I was noted at “best known” for my “perkiness”. Without analyzing why I feel the need to make people happy ( I will do that in a later post) I have to admit that I really, really enjoy it.

I currently work in home care. My patients range from basically healthy in need of companionship to end of life hospice. I feel responsible for the happiness of my patients and their families. I accept this responsibility with…

…happiness (of course).

  1. Call ahead- I always give a one hour window for my visit. I always call if I’m running early or late. I also ask if there is anything they need while I’m “out”. The patient often asks me to stop and pick something up for them. I’m happy to help.
  2. Arrive on time-See above.I am very careful about predicting the time of my arrival. Even if they patient is a little old lady who sits in her chair all day, she appreciates knowing what time to expect me.
  3. Listen-For real. I can’t just pretend to listen. When they talk about their hobbies or their kids or whatever, I listen. The next time I speak to them I will reference our previous conversation. They love that. They know I was really listening.
  4. Smile-A genuine smile can be hard if I’m not really happy. That’s ok. I’m practically always happy.
  5. Laugh-When I laugh with my patient, or make them laugh, its like a gold star that I earned.
  6. Ask good questions-It is so important to ask the right questions. I have learned to stop asking “How are you?” because I have received the response “How do you think I am?” one too many times. now I ask, “What’s new?”. To gather accurate information about the patients health and state of mind I have to ask smart questions. “Are you having any pain?” is just not enough. I also ask about discomfort and weakness. Then I ALSO ask about specific types of pain; back, knee, joint, etc. I know that a lot of patients don’t want to “complain” but I beg them to be honest with me.
  7. Give good answers-The answers are as important as the questions. The most important is when I don’t have the answer. If I really don’t have an immediate solution I promise to follow up, and then I do.
  8. Follow up-See above. Follow up is annoying for me, but I know how important it is for my patients. They are so happy when I get results and report back to them. Almost like they’re surprised that I actually did what I said I would do.
  9. Anticipate outcomes-This is where we use our crystal ball that is really our clinical experience, to predict the future. That is what I have to do every day, every minute.
  10. Remember the childrens’ names
  11. Remember the grandchildrens’ names
  12. Remember the pets’ names-I write them down in the patient’s paperwork. Yes, it is that important.
  13. Notice what is hanging on the walls-So much of what I want to know is hanging on my the walls. Are they a veteran? Are they married? Do they have children? Are the paintings on the wall all painted by the same artist? This is something that I actually look for. If so, I ask about the artist, which is usually the patient themself, or a family member.
  14. Do the laundry-How difficult is it to throw in a load of laundry? Even offering is a truly appreciated gesture.
  15. Wash the dishes-See above.
  16. Ask about hobbies and interests-My patients tell me about the most interesting hobbies; breeding horses (see previous post), keeping bees (stay tuned for this post), needlepoint, painting, gardening… 
  17. Take good notes-I take notes about everything. Sometimes the minute details are necessary to reference later. A seemingly unimportant statement or issue can become significant later.
  18. Bring gloves-You can never have too many boxes of gloves. This makes the patient and the caregiver very happy.
  19. Respect them-I am an invited guest in the patients home. I offer to take off my shoes, I ask permission before I sit. My patient is the boss. They deserve respect.
  20. Don’t argue-There is no situation I can think of where this would be appropriate or acceptable. Just don’t do it.

 

Lessons I’ve Learned:

  1. Its the details that count.
  2. Never underestimate your ability to change someone’s day. 
  3. Be present-whatever is going on in your life doesn’t matter when you’re with a patient. 

6 Reasons Why Home Care?

Home care, visiting nursing, community nurse…we are called many things. But that doesn’t change what we do. Nurses who make home visits, regardless of what we call ourselves, are all the same and have the best nursing job on earth.

I became a nurse for many reasons (see my previous post for details). I knew I needed a job right away so I interviewed A LOT. It quickly became apparent that I had some problems. First of all, I couldn’t work nights, this was non-negotiable. I was a single mother, and I had no one to watch my kids. This made me very unattractive to hospitals. I also didn’t want to work on Shabbos (Saturday), also a problem. I needed reasonable hours and/or something close to home (see single mother excuse). I wasn’t discouraged while I was going to all of my interviews and not getting any offers, I knew something was going to come up.

It did.

I got an offer from a staffing company to work per diem at their flu shot clinics. Back in the old days before CVS and Walgreens started giving flu shots, they used to hire companies to staff flu shot clinics at their stores. I went to pharmacies and large businesses and gave many, many flu shots. One woman complained that I didn’t really give her a shot (I did). She said it didn’t hurt at all and therefore I must be lying about giving her the shot. I told her it didn’t hurt because I’m REALLY good at giving flu shots. She didn’t buy it. After that moment I changed my pre-shot speech. Instead of giving the usual list of possible complications and contraindications I added, “the shot may not hurt, but if you want it to, I can arrange that.”

Eventually I was offered a spot in a training program at a home care agency. It was a dream come true (thanks to Sammy and Aviva). The program offered in class training for several months and then orientation in the field and a gradually increasing workload to productivity. It was a challenging time and I made plenty of mistakes but I made it through. I learned quickly that I had the perfect job. I stayed at that job for three years and my next home care position for three years and am at my current position for one year. I NEVER want to leave.

When you see a hospital nurse she is really busy, focused and usually very serious. Home care nurses are always smiling, why is that?

My patients often ask me about my family and how many children I have. Then they all ask exactly the same question, “When do you relax?” “I’m relaxing right now”, I tell them. That is not a joke.

  1. Independence. 

No one was looking over my shoulder. That may sound like a bad thing when you’re a new nurse, but it wasn’t. I may not have done things perfectly right on the first try, but I figured things out. Coming to the solution on my own was very satisfying and exciting as a new nurse. I had a supervisor and case managers in the office who could sometimes answer my questions when I could get them on the phone, but I learned not to bother.

2. Flexibility

I don’t just see patients in their homes. I have done new employee orientation, HHA classes, chart audits, quality control, community lectures, staff education and competencies. Sometimes its nice to spend some times in the office.

I decide when to see each patient. If the patient isn’t available when I want to see them (most were, they were usually homebound) we would chose another option that worked for both of us on a different day/time. This meant that I could go home and eat lunch…or go out for lunch (which nurses get to actually eat?). It also meant that I could schedule doctor appointments for myself or my kids and plan my patients around that appointment…or my kids school play, or a teacher conference, or a trip to the mechanic to get an oil change, or the post office. How do working mothers get things done?

3. The patients

I can sit with my patient for an hour talking about; the photographs on their walls, the numbers on their arm, what they’re cooking on the stove, the work they did “before”, the origin of their last name, their garden, their dog, their paintings, their piano…Of course I discuss their medical history but only after we have made friends. Why would I do it any other way? If I do a good job and I ask the right questions, most of my home and health assessment has been completed before I ask any of the questions on my nursing assessment. My patients are happy to share personal details with me because they trust me. When I teach new nurses I remind them that we are a guest in the patient’s home. We must ask permission before we sit down or place our bag on a chair.

4. The stories

My patients share the stories of their lives with me. Stories of immigration, illness, happiness and sadness. They trust me with the stories that make them who they are. I have met some truly amazing people who have experienced truly wondrous things. I am always humbled by the gifts they give me in the form of memories.

5. The money

The money is comparable to hospital nursing and the opportunity for overtime is usually available depending on the type of agency you work for. Even if your agency does not have overtime availability you can work for other home care agencies per diem while you are working full time for another. I have done this and it has created quite a financial opportunity for me.

6. The nursing

I have treated a wide variety of health issues. No matter what you may hear, home care IS real nursing. Wounds, staples, trachs, PEGs, foleys, sutures, vents, amputations and many more.

I may see a patient two or three times, or I may see them daily for years. Either way I am invited into their life. In this environment I have the ability to help my patients make real changes and I have the honor of watching it happen.

Prostitutes and Italian Restaurant Owners

How do you know if you are having a good day at work? What is the measurement of success or happiness with your work day?

Is it sales? Purchases? The size of a paycheck?

Before I became a nurse I worked as a real estate broker. My productivity was easily determined by the number of houses I sold and the number of apartments I rented. I enjoyed the concrete-ness of my successes. And I had great pride when I was able to relay this information to my co-workers, friends or whomever may have asked me about my work.

I imagine that in every profession the degree of success is measured differently.

Nursing, especially home care can be a very abstract type of nursing. My patients are not acutely ill but usually dealing with some type of chronic disease. My job is to provide care and education that most often does not produce concrete results. So, how do I measure my success? How do I know I am being a good nurse? How do I know if I’m doing it right?

I quickly learned that my productivity as a home care nurse was based on how many patients I saw in one week. It became very important to me to track these numbers. I still have all of the calendars I have used to track my weekly schedule and the patients I have seen each day, each week and how much overtime I got for every day since I started working as a home care nurse. This may seem obsessive but it was all I had. It was the only tangible way I could track my “success”. I didn’t really bother me because it was the norm with the nurses I associated with. They all talked about their “numbers” the same way.

A couple of years ago I had the opportunity to become wound care certified. This was very exciting for all sorts of reasons. First of all, I hardly knew anything about wound care and the thought of becoming certified was a bit of a relief for me. I had felt sorely inadequate because I really had no idea what I was doing when it came to wound care and it seemed that there was no one to help me. My supervisors were somewhat helpful, more helpful than the physicians, but I wanted more. The class was everything I had hoped it would be and more. One unexpected benefit to the class was the ability to literally measure my success as a nurse. I would measure the wounds weekly and track the improvement based on the decreasing size of the wound, resolved infection and decreased depth/tunneling. Until finally the wound was (hopefully) healed…I felt practically godlike.

I realize I am lucky to work at a job where my customers (patients) are always (mostly) happy to see me. I feel bad for people (dentists) whose customers are not quite so happy to see them…or worse, I feel bad for people who work at a desk all day and only see the few people they work with. I have not worked at that type of job in 16 years. At the time I didn’t mind it because I worked with a fun group but I can imagine how different that would have been if I hated my work or my coworkers. And I can imagine exactly what that is like because my dear husband works for the city of New York and not only does he hate his job but deeply dislikes most of his coworkers.

I get a lot of smiles, those are great. I get many thank-yous, those are great too. I recently got a “we so appreciate the work you do, it must take a lot of strength”, that was a particularly special compliment as it was given to me while I was crying in my patient’s home soon after his death. I get few hugs, they do not seem to be a popular form of gratitude. I have received quite a bit of chocolate, some cash, a couple of cards and various gifts including a dress, lipstick, a pin, and once I received a beautiful serving utensil from the adult child of a patient who had recently passed away.

As it turns out I can easily measure how good of a day or week I am having by counting how many kisses I have been offered by my patients and their families. The kiss is truly the treasure. Throughout history, the most valuable currency is that which is the least common, or most precious.

I suspect there are other professions that can also use kissing as their currency of success. My husband and son suggested that these are mostly prostitutes and owners of Italian restaurants. I’m not sure how accurate that is. I don’t know if prostitutes kiss their clients. I know that Julia Roberts had a strict no kissing policy in the movie Pretty Woman. I don’t have any other prostitute experience so I can’t say for sure. I do suspect that owners of Italian Restaurants get kisses a lot although I have never kissed one or seen one receive a kiss. This may be because I only go to Kosher Italian restaurants and they are filled with mostly Jews who don’t typically kiss the owner, maybe because they are Jewish and not usually Italian. I would have to do some research on that.

But the fact remains, when I get that kiss it fuels me and inspires me to do better and to be better. Hopefully tomorrow will be a kiss-worthy day.

Things I have learned:

  1. Gratitude comes in all forms.
  2. Success can be measured in countless ways.
  3. I (possibly) share one of my work goals with that of a prostitute.