1. Stoner, Marilyn Smith PhD, RN, CHPN, CNE

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As an admissions nurse in the Inland Empire of Southern California, I travel through a diverse geographic and economic area. I may go to a grand house on a hill or a humble home in a mobile park. The patients I see have one thing in common though, they have been told their chronic disease has reached its end, or their cancer is incurable. There is stress, confusion, and anticipation as I enter their lives and explain comfort care and life completion. Some patients I visit do not want to discuss hospice. They know they are dying; they just want to keep one last thread of hope alive by not discussing their pending death.


As I drive to the office, there is an error on the freeway signs I find reassuring. There are three signs indicating the distance to the offramp to our agency. I see these signs as a metaphor for the unpredictable nature of hospice work. The first sign indicates the exit is 1.5 miles ahead. The next sign says the exit is 2 miles ahead. The third and final sign correctly says 1 mile to the exit. Many days are like these signs; I think I am at a certain place with a patient and find I have not made the progress I thought.


I usually do two admissions a day. I review the charts and call to set up visits. I ask if there is anything I should know about visiting their home-gate codes, parking restrictions, and the presence of pets or wild animals. In the summer, there are a lot of snakes: rattlers, sidewinders, and others. I ask if there's mobile phone coverage at the home. Several outlying areas do not have reliable mobile phone coverage and the documentation will have to happen back at the office. I wear street clothes and name tag. I want to present a professional image of a nurse without reminding patients that they need a nurse.


The first home is in the foothills. The sky is filled with hot air balloons-common in this area. I ride up a steep gravel road and honk my horn, announcing myself to the family and any critters. Once I complete the assessment, I call the hospice physician and discuss my findings, the family's goals of care, and relevant data from the medical records. Data such as vital signs, palliative performance score, activities of daily living, body mass index, and oxygenation levels are important. The patient is eligible, so I order equipment and our agency comfort kit and alert the rest of the team. Before I leave the home, I write out a list of people to expect. Hospice is a team activity with case managers, advanced practice nurses, social workers, home care aides, chaplains, and volunteers.


My favorite part of the admissions process is the plan of care. I taught nursing for 30 years and loved showing students the beauty of having a patient-centered plan of care. This is where I put the information that does not easily fit anywhere else in the health record. The names of pets for example-patients are pleased when we remember the names of their pets. This is also where I describe the patient's answer to one of the most important questions: What is left to do? Some will ask for help in mending relationships, teaching their caregivers new skills, or getting out of bed one last time.


I repeat the same assessment at the next patient's home; however, this patient does not qualify. I know it is a disappointment to the patient and family when they learn that hospice is just beyond their reach. We will keep in touch with the family and when the patient's condition changes, I will be back.


My career has included decades of academic work mixed with hospice nursing. I have seen a lot of changes; however, the essence of hospice has always been the relationships between the staff and the patient and family. I hope that never changes.