1) What are the differences between home hospice and institution hospice?

Hospice care may be provided in a variety of settings, including private homes, nursing homes, assisted
living or smaller residential facilities known as "board and care" homes, hospitals, and inpatient hospice
residences of varying sizes. There are also 4 different "levels" of hospice care as defined by Medicare:
a. Routine care (most common), which is usually provided in patients' or family members' homes, nursing
homes, assisted living, board & care. Routine care nursing visits usually last an hour or less and take place
1-3 times per week. In routine hospice care, patients usually have one or more caregivers (family, friends,
hired caregivers) helping them with meals, medications, mobility, other activities of daily living. In
home-based hospice care, the hospice agency & its contracted vendors provide medications, equipment
(such as a hospital bed, wheelchair, walker, oxygen, etc.), and disposable supplies (such as gloves,
diapers, wound care supplies, skin crams, etc.), Other members of the hospice team providing home
visits include: social workers, chaplains, hospice aides (for bathing & hygiene), volunteers, and
sometimes the hospice MD or NP. Hospice nurses and other team members provide direct care to the
hospice patient and education/support to their caregivers, family and friends. In nursing homes, assisted
living facilities or board & care homes, the facility nurses, aides and other staff are the patients' primary
caregivers who interact with the hospice nurse and team members.
b. Inpatient respite care, which is usually provided in a nursing home for brief periods up to 5 days in
length, when the patient's caregiver at home needs a short break from caregiving (for a variety of reasons
such as caregiver stress/fatigue, caregiver health issues, or caregiver traveling).
c. Continuous care (also known as crisis care), where a hospice nurse, aide, or other team member
provides care in the patient's home or residential facility during brief periods of severe symptoms or crisis
that cannot be managed at routine level care.
d. General inpatient care, which may be provided in an inpatient hospice unit or facility, hospital or
nursing home 24/7 (lasting a few days to 1-2 weeks) for management of severe symptoms that cannot be
adequately managed in the patient's primary place of residence.

2) What are the priorities of care in hospice?

a. Pain and symptom management; maximizing comfort & minimizing suffering
b. Emotional support to patients and caregivers
c. Spiritual suport to patients and caregivers
d. Advance care planning (discussing & clarifying patient's/family's goals of care), completing a written
advance health care directive and/or Physician Order for Life-Sustaining Treatment (POLST) form.
e. Education about symptom management, care needs, disease progression (i.e. what to expect and the
patient's illness progresses), end-of-live changes,
f. Assisting with and facilitating final arrangements (mortuary, funeral planning)
g. Bereavement support/counseling (usually provided to surviving loved ones after the patient's death,
but also sometimes provided before the patient passes away if there are children or other family
members struggling to cope with the patient's dying process.
h. Volunteer services and support for patients and caregivers

3) What are the “checks” you would do in checking in a patient?

A hospice nursing visit includes:
a. Asking about the patient's symptoms (pain, shortness of breath, fatigue, nausea, constipation, anxiety,
restlessness, insomnia, etc,) and how well medications and other treatments are relieving these
symptoms.
b. A brief physical assessment/exam (vital signs, heart & lung sounds, skin exam, etc)
c. Treatments such as giving a medication, performing wound care, inserting or changing a catheter,
managing an infusion line or dressing.
d. Filling a pill box and ordering medication refills
e. Educating patients and caregivers about symptom management, disease progression, signs and
symptoms, end-of-life changes, etc.
f. Ansering patients'/caregivers' questions about items a-e.
g. Being a good listener and offering emotional support.
4) What are things that you do to help people be comfortable?
--See answers to question #3

5) How do you recognize that a patient is starting the process of dying?

End-of-life signs and symptoms (see 3a) increasing, as well as sleeping more & more, eating less & less,
becoming more withdrawn.

Here is a link to an excellent booklet that guides patients and caregivers through the physical, mental,
emotional changes that are commonly experienced by people approaching end-of-life:
http://www.qolpublishing.com/wp-content/uploads/2016/11/Eng-WDIN-HL-v1.2.2-Sample.pdf

Our Sharp Hospice patients and their caregivers are provided an almost identical booklet by this
publisher titled "When the Time Comes", and our nurses refer them to this booklet when teaching them
about what to expect as their loved one approaches end of life.

Also, I suggest that the actor who plays the hospice nurse and any other interested cast member read
some blogs written by hospice nurses. I Googled "hospice nurse blog" and found several thoughtful
reflections written by hospice nurses. Here's a link to one of those blogs that lists some essential skills
needed to be an effective hospice nurse:
https://www.nurse.com/blog/2014/09/15/hospice-nurse-whats-tool-kit/

Depending on the cast's other questions, I can provide them other links to very good resources for lay
people about hospice & palliative care.

See you in a few hours!

Dan

PS - Since 2015, I have served as a part-time Adjunct Faculty/Lecturer and coordinator of palliative care
curriculum at CSU San Marcos School of Nursing, so I teach a lot of this material to nursing students as
well as to nurses and other staff across the Sharp system, where I have worked at a hospice and palliative
care nurse for the past 20 years.

On Sat, Jan 5, 2019 at 10:41 PM Todd Salovey <tsalovey@ucsd.edu> wrote:

Here are some of our questions:

1) What are the differences between home hospice and institution hospice?

2) What are the priorities of care in hospice?

3) What are the “checks” you would do in checking in a patient?

4) What are things that you do to help people be comfortable?

5) How do you recognize that a patient is starting the process of dying?

THANK YOU!

Todd