Quarterly Inservice Test #2: Hospice

Hospice is a special kind of care for people who are dying that treats the physical, emotional and spiritual needs of the patient. Hospice concentrates on quality of life and making the patients final days as pain and symptom free as possible. Over 50% of hospice have cancer, other common reasons a patient is on hospice are heart disease, lung disease, end stage Alzheimer’s, AIDS, kidney disease and CVA. Any patient that has a life expectancy of 6 months or less and is declining aggressive treatment is eligible for hospice. A patent or family member can “REVOKE” or change their mind about being a hospice patient at any time. If a hospice patient or their family tells you that they have changed their mind notify Alliance Care immediately so that we can call the hospice and let them know. Hospice is supportive care it does not hasten a death or prolong life.

A DNR order means that the patient does not want CPR when he or she stops breathing or has cardiac arrest. A patient or their family can “REVOKE” or change their mind about a DNR at any time and request resuscitation. It is not required to have a DNR order to be on hospice. Please be sure to inquire about DNR status when starting a hospice case. Most patients on hospice will have a DNR.

If there is no DNR order start CPR and call 911
After 911 arrives and takes over –call the agency.
If there is a DNR order-
Be supportive to the family
Call the hospice and a nurse will come to the home and pronounce the patient and take care of final arrangements with the family.
Call Alliance Care and let the staffing coordinator know about the death.
While you are waiting for the hospice nurse-
Allow the family time to grieve. Straighten up the bed linens and lower the head of the bed, wash the patients face if needed. Other family may be coming to view the body at then home so make the area as pleasant as possible. Clear away unneeded supplies etc. NEVER COVER THE PATIENTS FACE unless the family requests it. DO NOT leave before the hospice nurse arrives unless instructed to by the staffing coordinator.

Lack of Appetite- The dying patient may not want food or fluids, this a natural part of the dying process, do not force fluids or food on a patient that does not want them. The patient may “aspirate” or choke on the food or fluid causing pneumonia or other complications. Many dying patients have dysphagia or inability to swallow. If a patient requests food and fluid and is able to swallow allow then to eat and drink what they can tolerate. Family members will often have anxiety when their loved one stops eating and drinking be supportive to the family.

Increased sleeping and drowsiness- Dying patients will spend a lot more time asleep and may be difficult to awaken. There may also be periods when the patients is wide awake, encourage the family to visit when the patient is awake.

Decreased urine output- The dying patient may have decreased urination and may not have regular bowel movements.

Nausea and vomiting- Nausea is the uncomfortable feeling in your stomach which may or may not lead to vomiting. If your client is nauseous ask the family if they have medication to relieve it. The medication may be a suppository, a pill or topical cream. Vomiting is the throwing up of stomach content’s, it is not the same as coughing up drainage from the lungs and throat. Common causes of nausea and vomiting are chronic pain, intestinal blockage, and fatigue. Patients also may have these symptoms as a result of medication they are taking.

What should you do when a patient is vomiting?
Raise the head of the bed or keep the client in a sitting position
If the client is not responsive or can not sit up, roll them on their side, do not leave
the client unattended.
Apply a cool wet cloth to the forehead
Avoid fatty foods and those with a strong odor
Offer fluids as tolerated, ice chips, ice pops, Jell-O, Gatorade ginger ale and other
Encourage fluids to be sipped slowly through a straw
If the client starts running a fever or has a new cough or congestion after vomiting
Notify the nurse ASAP. These are signs that your client has aspirated food or fluid into their lungs and will need medical intervention

Constipation- Dying patients are prone to constipation due to immobility and as a result of taking pain medication. Medications can be effective in treating constipation. Notify the nurse and family if the client has had no bowel movement in 3 days.

Diarrhea- Diarrhea is loose watery stools more then 3 times a day. Common causes are intolerance to certain foods, disease process, anxiety, effects of medications and viruses.
What can I do?
Increase fluids if tolerated
Offer small frequent meals instead of 3 large meals
Record bowel movements and report to the nurse
Keep the anal area clean and dry

Dehydration- in Hospice Care
Dehydration is not painful, studies suggest that dehydration may be a natural analgesic (pain killer) in dying patients. It is a natural process at the end of life and there is evidence that patients do not die sooner than those on artificial hydration ( IV”s). In fact hydrating a dying patient can cause other problems such as fluid overload, placing an undue burden on the body. It is very difficult for family members to watch their loved ones not taking food and fluids, be supportive of their feelings. The nurse or hospice team can help with the family if needed. Signs and symptoms of dehydration are decreased urine output, less congestion, fever, decrease in swelling, poor skin turgor ( skin is dry and has poor elasticity ), and dry mouth. Frequent mouth and skin care are needed
Mouth care for a sore mouth
Use a soft toothbrush and flavored toothpaste, if the mouth is too sore soft swabs or toothettes may be used
Dilute mouthwash- regular mouthwash may be to strong and cause pain
Leave dentures out until the pain is better
A prescription pain reliever for the mouth can be ordered by hospice
Keep lips moist using chap-stick type lip balm

Skin Care-
Bathing can be a very tiring process for a dying patient. Patients will often only need sponge bath with mild soap and water with good peri care alternating with a full bed bath. A dying patient’s skin is usually dry and fragile, do not rub skin wash gently and pat dry. NEVER LEAVE A WEAK PATIENT UNATTENDED IN THE TUB OR SHOWER.

Turning and Positioning-
A patient who is confined to bed and can not turn himself should be positioned every 2-3 hours. If your client has severe pain and is comfortable, this may be delayed.
Use a draw sheet under the patient for positioning, do not pull the patient the patient across the sheets, to prevent skin BURN from friction. Look for RED areas or skin breakdown and report it ASAP. Massaging skin with lotion will keep skin moist and help prevent breakdown. Use a light circular motion and do not RUB.

Breathing Difficulty-
Dying patients often become short of breath or have increased congestion in their airways. This may be due to the disease process or a sign that death is near. The patient may start to breathe rapidly and turn a bluish color. You may notice noisy breathing or wheezing.
What to do –
Remain calm
Elevate the patients head – NEVER LEAVE THE PATIENT FLAT
If the patient has , turn it on or increase the liter flow if the patient is already on oxygen.
The patient probably has medication to ease their breathing, ask the family if the patient has medication.
Notify the hospice nurse


Do not smoke, use matches, lighters or gas stoves near oxygen
Oxygen may be delivered via a mask or nasal cannula. The prongs of the nasal cannula must be in the patient’s nose to deliver oxygen to the patient, a mask must fit snugly on the face but not be too tight, this can be adjusted using the elastic strap on the mask
The nurse will let you know the regular flow rate for the oxygen. Home patients generally have an oxygen concentrator in the home that pugs into the wall, you will notice one or two sponge like filters on the sides or back of the machine. These filters pop out easily and need to be washed with warm water to remove dust at least every other day or whenever they are dirty. Dirty filters will clog the flow of oxygen to the patient. There should also be a water bottle (humidifier) on the front of the machine with 2 markings on the bottle the water level must remain between these lines. To fill the water, unscrew the bottle from the cap and fill with tap water and replace. If the power goes out there should be a portable green
oxygen tank available to use until the power is restored. Be sure to locate the tank BEFORE there is an emergency and know how to use it. If you do not know how, call the office and the nurse will teach you. There is no need for the humidifier bottle to be used on a portable tank. If the power is out over one hour call the office and hospice so that alternate arrangements for oxygen can be made. Depending on the size of the tank and liter flow the tanks should last from 4- 8 hours.

The oxygen is not flowing though the tube – what to do
Place the end of the cannula into a glass of water if there are no bubbles there is no flow of oxygen—check the water bottle if there are no rapid bubbles in the bottle, the problem is after the bottle. If there is no bubbling in the bottle, check that the connection to the machine is tight. The water bottle also has a screw type lid make sure it is tight. If the bottle is bubbling check the tubing, be sure it is tight on the water bottle, and follow the tubing to the patient looking for chair legs etc.that may be on the tubing cutting off the flow. If there is still no flow, change the tubing if there is a spare. If all else fails call the hospice nurse for assistance.

Itching is a common complaint for hospice patients due to disease process, dry skin, medications. What to do –
Bathe with warm– not hot—water
Add baking soda or bath oil to water
Wash gently DO NOT RUB
Keep room cool
Give fluids as tolerated
Use loose clothing
Apply skin cream
Ask family of patient has medication for itching, this may be an oral medication or a cream
Notify the hospice nurse if itching persists


When a patient is “actively dying” you will notice many changes these may or may not include:
Blue or purple color of the feet and hands which can extend to the arms and legs, these areas will also fell cool or cold to the touch
The patient will probably sleep most of the time and you may be unable to arouse the patient.
Be aware that the patient can probably hear what is said during this time. It is helpful and comforting to touch the patient and speak to him during this time.

Breathing will become irregular and may be noisy and congested. The patient may stop breathing for several seconds, this is called apnea. Apnea may increase as the process goes on. Fluid may accumulate in the back of the throat due to inability to cough up secretions or clear the throat.

Vital signs will change, you may not even be able to hear the blood pressure. The pulse will become irregular and radial and pedal pulses may be difficult to count as circulation worsens. The pulse may become rapid or slow and the blood pressure is usually very low. The patient may suddenly run a fever.
Urine output may become less and urine may be dark and foul smelling.

    *3 in-service credit hours

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    #1: Your patient becomes short of breath, what should you do?

    #2: Your patient dies and has a DNR order the family wants you to start CPR, what do you do?

    #3: A patient on hospice should have a life expectancy of

    #4: Signs of ” active dying process” include

    #5: Apnea is:

    #6: Mouth care for a sore mouth should include

    #7: Care for a patient with itching includes

    #8: Oxygen care and safety includes

    #9: Care of the patient with nausea and vomiting includes.

    #10: Signs of dehydrations include

    #11: Your patient dies while under hospice care and there is a DNR order, what should you do?