What hospice doctors need to know when they do a home visit

It's a major change for some

Making a home care visit is one of the biggest challenges for physicians and other health care practitioners trained in the medical model because they're not in control of the interview.

While hospices train their nurses and nursing assistants to work in a home care setting, they may be overlooking the needs of hospice physicians and nurse practitioners, experts suggest.

"When you see patients at an office you decide when they come in, decide when to see them, and you walk away when you're finished," says Deidra R. Woods, MD, FACP, CMD, hospice medical director of LifePath Hospice & Palliative Care Inc. in Ruskin, FL.

"You're really controlling that interaction," Woods adds.

It's an entirely different scenario during a home visit.

"When you enter someone's living space, they are the king of the castle, and you're no longer in your own environment," Woods says.

Physicians and nurse practitioners sometimes find themselves surprised and uncomfortable in a home care situation.

For instance, Woods once was visiting a man who was sitting on his screened-in porch, where it was very hot. As the man talked with Woods, the man's daughter held a hand-held video camera and was videotaping the interaction.

"It was quite a surprise," Woods says. "I said, 'Oh, how unusual,' and the daughter was very clear that she didn't care who her daddy was talking to; she was taping her daddy in his dying days."

Woods had been uncomfortable, thinking the camera was connected to the care she was providing, but to the patient's daughter it was all about recording his last moments, even when he was talking with his hospice doctor.

As LifePath Hospice's business has grown, the hospice has hired additional nurse practitioners and physicians who previously had not done home visits, says Terri Massaro, MS, ARNP, AOCN, APRN, BC-PCM, a nurse practitioner with LifePath Hospice & Palliative Care in Tampa, FL.

"So we were talking in our medical staff meetings about what makes a good hospice visit and what were some of the trials and tribulations of them," Massaro says.

As a result of these conversations, Woods and Massaro have spoken at national hospice conferences about how practitioners can achieve successful home visits.

"It's difficult because you are on the patient's turf, and you are a guest in their home and that kind of shifts the power," Massaro says. "It's still a clinical visit, but you're a guest in their home, and it's easy to lose boundaries when you're looking at pictures of their grandchildren and petting their animals."

Woods and Massaro offer these ideas of the challenges to successful practitioner home visits:

  • Environmental challenges: Home visits may involve uncomfortable temperatures and unsanitary conditions to which practitioners must adjust.
    "I've had shoes melt, the soles come off my shoes because it was so hot," Woods says. "Naples [FL] is pretty hot about 360 out of 365 days of the year, and we had one patient who lived in a shack with the windows nailed shut."
    The interior of the building was incredibly hot, and the soles of Woods' shoes literally came unglued.
    "You have to carry a big jug of water and stop at Burger King so you can breathe for half an hour," Woods says.
    Besides lacking air conditioning, some patients' homes have no heat in the winter or running water year-round, Massaro notes.
    "You have to be prepared for that because not everyone lives in a nice, clean, cozy home," Massaro says. "You want to be dressed in flip flops and shorts, but have to go out there dressed in a professional manner because otherwise it will feel more like a social visit to the patient."
    Practitioners can talk with patients about their environmental challenges and how to handle them, Massaro suggests.
    "If there's a problem and they can't pay for their electricity, we get counselors involved to see if there's any way to negotiate with the electric company to make this person comfortable," she says. "Or we may have the person move out of the house; home visits aren't for everyone."
    Another challenge might be providing handicap accessible features to homes, Massaro says.
    Before the medical staff visits a home, other hospice professionals will identify environmental concerns, such as whether it will be possible to bathe the patient, she adds.
    "If you come from a hospital or clinical setting, you are used to having a clean, sterile environment when seeing patients," Massaro says. "You're not going to have that when you go into a home, and you need to be prepared."
  • Setting boundaries: It's challenging for medical professionals to remain detached when they see unsettling things in the patient's environment, such as a lack of electricity or running water, Massaro notes.
    "We have to go in as medical professionals and then get the right people involved and not fix the problems ourselves," Massaro says.
    "Families want to be gracious, and oftentimes, they want to give you a cup of coffee or something to eat, which makes it more social," Massaro says. "But even crossing that boundary can be a problem."
    Massaro cautions staff against accepting the coffee because it sets the expectation that the patient's family will do something for the hospice professional at each visit, and this distracts the professional from doing his or her job.
    Fortunately, hospices typically have a policy that outlines what to do when offered gifts by patients and their families, Woods says.
    "People who are attracted to this work have an unfortunate propensity to becoming enmeshed in the family system," Woods explains. "So we recognize that as an industry, and it's an issue we're aware of and address proactively."
    Hospice policies can range from forbidding staff from accepting any gifts to having them redirect gifts to the hospice foundation, she says.
    "If a family wants to recognize a caregiver who has done a particularly good job, then they can do so with a letter of thanks to the person's supervisor," Woods says. "But it's not appropriate to accept material goods from dying people — it's fraught with too many ethical issues."
  • Coping with pets: "People love their pets, and we've seen everything at home visits from snakes to ferrets to big dogs," Massaro says. "There's always a safety concern."
    Some health care and hospice agencies will mandate that the animals be put away in a separate room during the visit, and other agencies permit but do not require staff to make that request, she says.
    "I've had birds crawling up my shirt and dogs slobbering on me and cat hair covering the back of my pants when I leave, and even a pet squirrel crawl up my leg," Massaro says. "I love animals, but not every practitioner loves animals."
    Plus, there have been hospice staff members who've been bitten, and that's always a concern, she adds.
    Woods says she also loves pets, but draws the line at birds.
    "I have difficulty with the bird that is flying around the house and lands on my head," Woods says.
    And it's surprising how many patients will let their birds defecate all over the house, creating a sanitation nightmare, she notes.
    "It's their bird, but I absolutely will ask them to put the pet somewhere safe," Woods says.
    In one hospice situation, a nurse practitioner whose fear for dogs was phobic asked that the family put the family dog away during her visit, Woods recalls.
    "The family member asked for a different medical provider because she was insulted that the nurse practitioner asked her to put the 150-pound dog in a back bedroom," Woods says. "I don't expect medical providers to go into a situation where they're not comfortable, so we asked a different medical provider to go into that home."
  • Time management and scheduling: Scheduling and time management are challenging for medical practitioners who are used to seeing many patients in one setting, with office visits running back-to-back.
    "Time management is something you can get better at with experience," Woods says.
    "We initially find that when people start to do this work it can be overwhelming, and it may be difficult for them to set [time] limits because they are in the patient's environment," Woods explains. "It's a skill you get better at over time."
    And there always will be the occasion when the doctor or nurse practitioner has to wait at the house until someone else arrives because of an emergency that occurred, she notes.
    Another challenge is negotiating the geographical distances involved in hospice home visits, Massaro says.
    "With gas costs being so high, you want to keep your visits within a reasonable geography for the day," Massaro says. "You don't want one visit on one end of town and another one on the other end of town."
    Plus, hospice medical practitioners will need to make certain their automobiles are in good condition and are well maintained and that they pay close attention to their surroundings as they drive in new areas, Massaro says.
    "Safety is always of utmost importance," she adds.
    "Someone always needs to know what your schedule is," Massaro says. "And hospice employees learn about safety in orientation."
    Also, because the hospice has wireless Internet access, employees can visit MapQuest in their automobiles if they need to find a new home or if they get lost," Massaro says.