In order to be qualified for hospice services, a patient must have documentation from their physician stating that if the disease progression occurs as expected, the patient will have six months or less to live. If a patient lives longer than six months, they are still eligible for services if they are still deemed "terminally ill" by a qualified hospice physician. Once admitted to the hospice program, the patient begins two ninety day benefit periods followed by an unlimited number of sixty day periods. At the beginning of each period, the hospice physician must reassess the patient and resubmit documentation if the patient is still appropriate for services. This is regulated by Medicare. If a patient is assessed and the physician no longer believes that the patient is terminally ill, the patient may "graduate" from hospice, however when the patient's illness progresses further, services may resume.
A few of the patients that I see have been on hospice services since as far back as 2008. Then there are those whose families wait until the last few days or weeks of the patients life to apply for hospice services.
When the patient's hospice nurse believes that the patient is becoming imminent (within a few days of death), the nurse will call in continuous care. Continuous care is a part of hospice services that allows for a continuous care nurse to be with the patient 24/7 until the patient passes away. This allows the family to refrain from sending the patient to the hospital and helps relieve the family's stress at the very end of the patient's life.
Throughout my internship, I have seen quite a few patients that are on continuous care. Sometimes, these patients can be on continuous care for much longer than the expected few days. One man that I saw had a continuous care nurse at his house for over two weeks. Then there are others, who do not display signs of imminent death and therefore are not receiving the continuous care service at their time of death. This just goes to show that death cannot be predicted. There are certain signs that doctors and nurses look for toward the very end of life such as mottling of the skin (blue or purple coloring), apnea, and congested breathing (also known as the death rattle), but not all patients experience these changes.
One patient that I have been seeing since the beginning of my internship passed away on Friday morning. This woman had a diagnosis of Alzheimer's disease and when I saw her last week, she was the same as she had always been. I was definitely shocked to see her name on the discharge list that day. I know that I am interning in hospice and that all of the people that I am working with are terminally ill, but I did not see her death coming at all.
Throughout my internship, many patients that I've seen have passed away, but this was the first death that I was really affected by. So what do you do when a patient that you have grown close to passes away somewhat unexpectedly? You have to allow yourself a few minutes to reflect and process what has happened. It's inevitable that working in hospice, you are going to lose patients that you really enjoyed working with, but it's still incredibly important that you allow yourself to feel whatever feelings arise. It's difficult work, but it's also extremely rewarding and comforting to know that you made a difference during the end of somebody's life.
How do those of you working in hospice take care of yourselves when a patient dies?
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