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Intensive Care Unit for the End of Life

A partnership between two Texas entities brings a greater focus to patient care.

At Texas Health Arlington Memorial Hospital, an inpatient hospice unit created in collaboration with Community Hospice of Texas provides quality clinical care and psychosocial support for patients dealing with life-limiting illnesses.

"When hospice patients living at home or in long-term care settings face medical crises, have a significant change in status, or experience a fall or other sentinel event, their case managers can follow Medicare guidelines to refer them for admission here," said Sue Ellen Grounds, RN, CHPN, nurse liaison for Community Hospice. "It's an intensive care unit for the end of life."

Best of Both Worlds

The unit is designed to provide hospice care episodically, based on the needs of the individual patient, said Grounds.

"Hospice levels of care are very fluid, and there's no limit to the number of times a patient can access inpatient care," she explained. "We need to follow Medicare guidelines for the level of care, but within those guidelines, someone may be admitted anywhere from 0 to 10 or more times during the end of life."

Oncology nursing supervisor Mary Teague, RN, said inpatient nurses play an important role in the death and dying process due to hospice patients needing more intensive nursing care than what is offered in the home or in LTC.

"We're able to be there for them 24/7," she said. "It's very comforting for families to know their loved one has immediate access to hospice professionals to help them through the end of life."

With the support of Tony Su, MD, FCCP, medical director of Community Hospice of Texas and a pulmonologist and intensivist at the hospital, the inpatient hospice unit offers patients and staff members the best of both worlds.

"Community Hospice has ongoing educational programs that integrate the latest evidence-based information about symptom management and palliative care for hospice nurses," said Grounds. "We do our best to make sure nurses both in the community and within the hospital have the knowledge and skills they need to provide the best possible hospice care."

Teague appreciates the melding of hospice and acute care.

"I'm a bedside nurse two days a week, and our informatics team designed charting specifically for hospice care," she said. "It addresses more of the pain, comfort, and spiritual care rather than vital signs and other topics more common in acute care charting. We've been doing this with Community Hospice for a few months now, and we've been working together to improve nursing care for our inpatients."

Holistic Care

Although hospice patients are housed on one particular unit, they benefit from services of many professionals and ancillary staff who contribute to holistic care, Teague explained.

"Our nutritional service department creates special meals for our patients and guest trays for family members, physical therapists come for range of motion exercises to promote comfort, our chaplains are involved in spiritual care, and volunteers come to the unit regularly to interact with patients and families," she said.

In addition to traditional nursing interventions, inpatient hospice patients benefit from complementary modalities to enhance quality of life. Oncology staff nurse Jane McNelis, RN, OCN, CCAP, and Ronnie Sullivan, RN, CCAP, nurse manager of oncology, hospice, and outpatient infusions, recently completed a clinical aromatherapy course for healthcare providers.

"We're finalizing a protocol that will allow us to use essential oils to help patients relax, make pain medications more effective, and promote spiritual wellbeing," said McNelis.

The two nurses are doing their part for evidence-based holistic care by taking part in research projects based on how essential oils relieve agitation at end of life and the affect of aromatherapy on constipation, said Sullivan.

"We can bring symptom relief to patients without giving excess medications that can cause additional side effects," she said.

Working with Families

Hospice nurses also help family members understand the need for the inpatient care, Teague added.

"We let them know the admission is most likely for a short time, and that they shouldn't feel guilty about it," she said.

The word "hope" has new meaning once a patient enters hospice, McNelis explained. "It's no longer hope for a cure, but instead hope that the end of life will be pain-free and their loved one can die with dignity."

Nurses explore the family's expectations and tailor nursing care accordingly based on the staff's interdisciplinary approach which is designed to give families have peace of mind and allow them to seek respite to take care of their own needs, said Sullivan.

"They know someone who really cares about their loved one is keeping a close watch," she said.

McNelis recalled treating one older gentleman who often became restless during the day. Community Hospice brought in a volunteer to sit with him in the afternoon, which gave the family some respite time, and was comforting to the patient as well, she said.

"Another man wanted to be with his wife as much as possible, so he essentially lives on the unit," said Grounds. "He has a place to sleep, a small refrigerator for his own use, and goes to and from work each day."

A Great Honor

Hospice staff recently had the opportunity to care for one of their own, an employee who had been part of the hospital family for many years. "It was a great honor to be able to provide comfort and dignity for a co-worker and peer as she transitioned from this world," said Teague.

Community Hospice and Texas Health Arlington Memorial have been partners since the hospital provided seed money to form the non-profit hospice in 1996. Aside from the inpatient hospice unit and the staffs are also working on a creating a palliative care unit over the next year, said Grounds.

"Community Hospice does a lot of things for their patients they aren't reimbursed for, and it's a huge privilege to be associated with a company that truly puts the patient first," Teague concluded. "Texas Health is a faith-based organization, and having Community Hospice as a partner has brought our organization to another level of compassion."

Sandy Keefe is a regular contributor at ADVANCE.


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I believe that this is something more hospitals need to invest in I belive in Hospice and Pallitive care and it is not used enough here in our town.

Theresa Morton,  RNCWOCNDecember 10, 2009
Nacogdoches, TX


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