I get this question a lot .. should I go straight into hospice as a new grad nurse. I’m going to make some people unhappy but IMHO .. NO.

Aside from the skills like, accessing a port, putting in a catheter, doing complex wound care that you won’t have as a new grad. You also won’t have the equally as important skills of identifying the signs of approaching death, managing symptoms you never heard about in nursing school, or talking to families about what is unfolding. And you will have to do all of those things ALONE .. in people’s houses where you have no control over the environment.

If you truly feel passionate about being a hospice nurse, your best chance at success is to work for a year MINIMUM (I recommend two or even three) in long term care, oncology or ICU. Otherwise you are setting yourself up for failure.

The caveat to this is if you can get a residency in an inpatient hospice unit where you will be working side by side with experienced nurses. If you’re lucky enough to get that .. go for it!

I have found that the single most important thing you can do to manage time is point-of-care charting. If you’re like I used to be, you write your notes by hand with the intent to transcribe them into the computer after you get home. But once you get home, life happens. dinner needs to be cooked. The pets and/or kids need taking care of and documentation gets pushed out later and later. Then you find yourself sitting down at 10 pm finishing your charting. This sucks in so many ways.

• Double documentation .. total time waster!

• You may have only worked 8 hours total but it feels like 14.

• Documentation saved for later is less accurate.

• Anyone caring for the patient between the time you saw them and when you finally get your notes in, won’t have an accurate picture of what was going on with them.

I’ve heard some nurses complain that point of care charting is prohibitive to therapeutic care because it puts the computer between you and the patient. I can’t think of any time recently when I went to a doctor appointment and there wasn’t a computer in the room. People are used to electronic charting so it shouldn’t be a surprsie to them when you do it.

The main keys are communicating why you are doing it, “I want to make sure I accurately capture everything that is going on so everyone on the team will know what we talked about”—and knowing when to set it aside.

Also, giving yourself grace. It takes a little bit of time to get the hang of it. Start with just opening the computer in your visit to do your med reconcilliation (which PS you should be doing anyway!).

There are going to be times when it just feels impossible to chart at the bedside … shit happens when someone is dying! But I guarantee if you can try to get the majority of your documentation done in most of your visits, your life will change!

As much as people don’t like talking about death, you will often get the question, “how long?” Since you probaby don’t have a crystal ball in your car stock, what is the best answer? The truth, followed by your best guess, which goes something like this:

“We don’t really know for sure, death is unpredictable. I can give you my best guess but I will give you the worst case scenario. That way if I wrong it’s a gift and if I’m right your prepared.”

I like to use timeframes that are fairly broad vs trying to give them “a day or two”.

Weeks to months, days to weeks, hours to days, minutes to hours.

The closer the person gets to death, the more accurate my predictions have been. For me, the telltale sign is when they start thrusting their tongue forward with breaths. That’s usually in the last minutes of life.

Don’t use them. Dead, dying, died, it is what it is. Enough said.

Okay, okay I’ll give you a little more. People are obviously emotional when their person is dying so being very clear about what is happening is important. Especially if it’s someone who lives far away and your communicating by phone.

The expectation for our patients is death, so it shouldn’t be a surprise when you tell them they’ve died.

If you’re pronouncing with the family in the room, I think it’s fine to give them a little nod and a “he/she’s gone” because again, they’re already aware that is most likely what happened.

But avoid things like “he’s passed on” or “she went to heaven” (I know of doctor who said this once and the family who wasn’t religious was like WTF??)

Vital signs on hospice patients are really only useful when they’re used to help determine eligibility. When it comes to assessment, it’s more important to pay attention to the person, not the numbers. Ask yourself, what will I do with the information? If the answer is nothing, you probably don’t really bother the patient to get them. Some people find having their BP checked uncomfortable and what if they have high blood pressure, are you going to call the doctor for to get an order for anti-hypertensives? probably not. Conversely though, if they are on BP meds, you might want to check it occasionally to see if it’s time to stop them.

If the patient is short of breath but their sats are 95%, will you withhold the morphine? NO! If they’re O2 sats are low, will you be giving them medication or starting oxygen if they aren’t short of breath? Also, no.

And speaking of oxygen …

I worked with a nurse once who said the US is the only country in the world who puts oxygen on dying people. I have googled to see if there are stats on this and haven’t found any but anecdotally, I believe that could be true. As an IPU hospice nurse I had many a patient arrive from the hospital with oxygen on and no history of respiratory disease.

We use oxygen for comfort in hospice. If it makes a patient more comfortable then by all means, let them have it. But not everyone finds it comfortable. I’ve had more than one family member tell me they were fighting with their person because they kept pulling off the oxygen.

Remember, morphine is the gold standard for treating shortness of breath. If they don’t want to use oxygen, don’t make them!

Ugh. The worst part about the dying process. Yes, we have anticholinergics to try to dry them out, atropine, scopolamine, glycopyrrolate, I’ve administered them all. But let’s be honest, they don’t work for shit. Well, they do work for drying out the mouth and thickening the secretions but that’s about all.

In my experience (and that of many of my colleagues) education and repositioning are the best methods to reduce the noise.

Education: We swallow our saliva all day long without even being aware of it. But when a dying person loses their ability to swallow, the saliva builds up in the airway and as they breathe the air moving over it makes that noise. They aren’t aware or bothered by it and they aren’t going to drown.

Repositioning: My trick is head of bed up, put them on their side. Either side, doesn’t matter. I have found this to work like a charm almost everytime.

Fun fact about the death rattle, it’s highly predictive of death. Most people will die within 48 hours of onset.

For God’s sake DON’T LET YOUR PATIENT GET CONSTIPATED!

My nurse kryptonite is poop … absolutely hate it so that alone was a great motivator for me to keep them going on their own.

Seriously. As an IPU nurse I had so many patients I had to disimpact and they rarely came in for constipation. They were there for terminal agitation but all they needed was a poop.

Here are some important poop facts to keep in mind:

• People make waste even if they aren’t eating.

• If a caregiver tells you their person is all good now because after several days of not pooping, they just had diarrhea .. RED FLAG! They might be leaking around an impaction.

• Every person who is on opioids needs to be on a bowel protocol even if they are actively dying because we don’t know how long they will take to make their exit. A suppository every three days should suffice.

Should you get certified? I’m all for certification. It shows a level of commitment and excellence to your chosen field of hospice. Also, you will learn a lot when you study for the exam. For instance, lemon glycerin swabs are contraindicated for hospice patients. Did you know that? I did .. because I had to study for my certification and that was a question on the test! By the way the why is that they’re too drying for our dehydrating patients.