any tips?

[marie337]

I'm an MS4 starting a Hospice rotation next week. It's at the local hospice house, no home visits that I know of. It's my understanding that notes are only written once a month and most of the orders are standardized on forms. What things should I be prepared for, reading up on, what will my role be, etc.? Any tips?
I don't think they get medical students very often on the service and I hear that the attending is overworked and quite stressed out so I'd like to be as useful as possible!

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[signomi]

Hospice House? As in long term care hospice patients and not the inpatient unit used for acute symptom management or active dying?

In the long term care section, if it is a high census busy place, there are always patients that need to be seen for some change in status (ie new symptom or issue etc). Talk to the nurses, they will know which patients need an MD visit or even just some attention.

 

[bkdaniels]

From my experience with Hospice, there is not a whole lot you can do. If you have a "treatment" frame of mind, then you might want to consider a career in another area of medicine. The primary example of me saying this is because my Uncle spent his last week of life under the care of a Hospice Physician.

He had reached the end-stage of esophageal cancer. The chemotherapy could not do anything to stop or slow the metastasis of the cancer so his doctor ordered a DNR (Do Not Resuscitate) order. All meds were stripped from him, all IV's, and food was only give to make him "comfortable." "Comfortable" is the magic word in Hospice. This is going to be your primary duty, to keep the patient comfortable.

This might seem easy, but there is a fine line in Hospice, from a legal point of view. Many of the patients who come there are in situation similar to my Uncle. Their families have a no tolerance policy to pain. Hospice institutions are in constant legal battles because their loved one complained about pain. Many times, this pain is related to their advanced disease. Because of that, Hospice Physician's chose to keep the patient under heavy sedation with pain medication - which by practice is the only way to prevent the patient from hurting.

When a DNR is ordered or no current FDA approved treatment will benefit the patient and no surgeries can be performed, those will be you most difficult cases. You have to be emotionally detached and have strong morally grounded. When a man or woman goes into cardiac arrest, for example, begin to pull you towards him, pleading for you help, and all you can do is watch him or her die you have to be confident that there is a fate worse than death. The old Western phrase "You are better off dead" works well in Hospice work.

Do not get me wrong, Hospice was able to do something that me nor my family could do; and that was sit there and watch a major disease, i.e. heart disease, cancer run it course. My Uncle vomited black blood every time they attempted to feed him. He vomited like 4 times per night. The pain from the growth of the tumor was so great as it pressed up against vital organs and nerves that if it wasn't for the pain pills, no one in my family wanted to see him like that. There are constant stories of Hospice Physician's falsely documenting a patient was in pain so that they can prescribe them narcotic pain medicine. By narcotics not metabolizing properly in a person with, let's say, compromise liver function the drug has a longer half-life they have a greater chance of overdose. I don't know how true it is, but I strongly felt for my Uncle, that was the best way for him to go.

"You are not put on earth to be everywhere, but somewhere. You are not here to do everything, but for a purpose..." and I paraphrase in the words of Preacher Mike Murdock. So, this may very well be your calling. Good or bad in Hospice care, you have a chance to change it for the better. Of all the healing and miracles that occur in modern medicine, there is certainly still a season when one shall die.

 

[brimcmike]

Your job first and foremost is to observe and learn.

Observe, observe, observe.

Most physicians trained in the last half century or so are not well-trained with respect to prognostication (in the past, the chief job of the physician, fatal or not? hopeless or not? sooner or later? etc.). Note with care how patients progress, and how quickly.

You can certainly learn by doing in the sense that you can most likely see patients, get histories, and perform exams. Be careful in communicating any preliminary assessment or plan before presenting to your attending.

The assessments and plans in H&PM are specialized and different from the focus of most of your previous education. They need to be congruent with the treatment goals for that patient and within the parameters and limitations of H&PM. Your attending has a particular practice style and practice environment; respect that and volunteer few opinions before you get to know your attending and the practice parameters well.

Both hospice and palliative care focus on helping patients be comfortable by addressing issues causing physical or emotional pain or suffering.
Palliative medicine relieves the pain and other symptoms patients suffer due to serious illness, including cancer, cardiac disease, respiratory disease, kidney failure, Alzheimer’s, AIDS, ALS, and MS. The goals of palliative care are to:

• reduce suffering,
• improve the quality of a seriously ill person’s life, and
• support that person and their family during and after treatment.

Hospice care is for patients with a terminal diagnosis who are no longer seeking curative treatment. The focus of their care is on relieving symptoms and supporting them as they approach the last stages of life. The specialty brings special attention and expertise to the problems of such care to these patients with life-threatening, life-limiting and serious conditions, including treatment options, adjustments and interactions, including dosing adjustment.


The practice is universally run with integrity. Because in H&PM the margins are slim and the benefit is generally capitated, and doesn't cover things like procedures. Whatever bending of the rules that I've seen have to do with dis-enrolling patients from hospice back onto their primary coverage, to get one-time, expensive palliative procedures for optimal patient care done (like venting G-tube placement for impending GI obstruction, etc.), and then re-enrolling the patient back into hospice. This is done to prevent the program's budget from being busted, and keep the doors open for present and future patient.



Learn, learn, learn.


Resources:
http://www.eperc.mcw.edu/ff_index.htm
http://www.aahpm.org/cgi-bin/wkcgi/search
http://www.aahpm.org/resources/
and their parent URLs

 

[signomi]

I don't think posts that gratuitously dredge up a year old post in order to cast aspersions and libelous commentary on an entire profession even deserve a response.
A pre-med student with such hate filled ignorant commentary is a sad sad affair. Good luck.

 

[beanbean]

Same poster was over in the EM forum calling paramedics and EM docs a joke. Apparently he/she is an expert with vast experience in hospice and EM!