Your 69-year-old patient is declining. He’s been in the hospital for three weeks with multiple infections following chemotherapy for Stage IV colon cancer. Additionally, he has liver metastasis. He is full code status, so he would require full CPR support in a life threatening situation. Looking at him now, you doubt he will ever be strong enough to get more treatment, as he is bedbound, cachectic, sleeps most of the time, and moans in pain a lot. However his wife keeps talking about more chemotherapy.
He has periods of being awake and lucid. And you wonder what he wants, because this period may be the window to have a discussion. Hospice would be an option if he can get home. But no one has mentioned it, the doctor hasn’t spoken about the treatment plan, and no one is talking realistically about his future.
You wonder if you should try to open up a conversation. This is a sensitive topic, and you need to know more about the patient’s perspective before beginning. So where do you start?
The first step is to listen for openings. If the patient says something like “I'm so weak. I don’t know how I’ll manage being home,” you have an opening to ask about his concerns.
If you don’t hear an opening, then make an observation about his condition such as “I know things have been rough lately. What has the doctor said?” This will give you a sense of his readiness to hear information about end-of-life care. You can also ask the physician what discussions he/she has had in the past with the patient, to give you more information.
Move to more specific questions once the door to the conversation has been opened (even if the opening is just a crack). For example “I see how weak you are. What are you hoping for now?” This question can give you a clearer picture of where the patient and his spouse are and when to bring up hospice.
Once you have begun a conversation about the future, you can bring up hospice as one alternative to staying in the hospital, especially if the patient mentions how important getting home is to him. You may say, “There is a special program that can help you get home. This program has experts in managing pain and will give your wife a lot of support. It is called hospice.” Many patients worry that being at home will add to the caregiving burden of their loved ones. Emphasizing the support of hospice can be a relief. Even if your patient is unrealistic about the future, giving this information as an option can give him something to consider in the near future.
“Have you ever heard of hospice?” is an important follow-up question. Most people have heard of it, but some may have negative associations with the focus on death or presume it’s just for the last few days of life. Providing education about what hospice provides (rather than focus on what it doesn’t do), and that services are provided for weeks or months at home, can lead to obtaining a referral. Once some interest is expressed, the patient and family are generally open to meeting with the hospice provider.
Starting these conversations is not easy, but it is very rewarding to know you helped a patient achieve his goal of getting home.
Resources for talking to others about their end-of-life wishes are available at:
The 2013 Nurse Compensation Survey Results Are In Michelle Bragazzi, BS, RN, 5/3/2013 32 In February, TheONC surveyed more than 600 oncology nurses to find out more about their careers. We wanted to know if they felt adequately compensated and satisfied within their ...
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