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Wednesday, May 22, 2019

In Hospice, Time is an Illusion

by Lizzy Miles (@LizzyMiles_MSW)

Lately I’ve been thinking a lot about the perception of time and how it affects our patients. Because their time is limited, their perception of time and its value can often be magnified. This is our job, but this is the patient’s LIFE. We have to remember that for our patients, they may be hyper-focused on time. How do we help them feel good about timing and the time we spend with them? We can do this by being mindful of how we use our time with them and also how we show respect for their time.

Set expectations
There is research in the ambulatory care arena that says that patient satisfaction is increased if a patient knows how long they are going to have to wait to see the practitioner. It would be reasonable to conclude that this would apply to hospice visits as well.

Intervention: Always give a time range for when you’re going to visit so you bake time in for traffic, other longer visits, etc.

So much caregiver distress could be alleviated if we just set expectations appropriately.

• On admission, make sure you tell patients and families the visit frequency for each discipline.

• Inform family members how your organization’s paging system works. Encourage them to let us know when they call how important their call is. Encourage them to call back if they haven’t heard back from the staff member and they feel it’s urgent.

• If you’re taking a message for another staff member, don’t make promises for others. If you know there is a potential for delay in the other staff member calling them, let the patient know.

Coordinate with all team members to address patient/caregiver crises in a timely manner
Our perception of a reasonable response time for telephone calls or visit likely differs significantly from what a patient or caregiver feels they need. We may think two or three hours is a reasonable response time to visit when a caregiver calls about a new symptom that is causing panic. The caregiver may want us there ASAP. When we can’t get there quick enough, what happens? They call the squad. Emergency room visits for normal hospice symptoms are excessive, unnecessary and can be avoided with coordination.

Sometimes, the staff member who is initially requested may be caught up with something else, and another team member may have to temporarily assist.

Here are some options to consider as well:

Intervention: Can another staff member return the call to find out what is going on?

A social worker may be able to talk to the family member and learn that the caregiver simply wants to order equipment or supplies. Even if the need is for nursing, a call from a social worker to find out what’s going on can be helpful. The need may be for a question to be answered that social work can coordinate with the primary nurse or triage. If a nursing visit is needed, the social worker can inform the family the estimated time that the nurse will be coming out. Sometimes an estimate in itself all the reassurance the family needs.

Is it a matter of the caregiver just not knowing what medicine to administer and education can be provided on the phone by a triage nurse if primary nurse is unavailable?

There is nothing worse for families to not receive a call back when their question was a simple one that could be answered with instructions and education.

Is the social worker or chaplain available for a visit? Sometimes the family wants a ‘body’ from hospice and are comforted by the present of a social worker or chaplain.

Even with patients who are actively dying, I’ve found that as a social worker there is a lot we can do at the bedside to help the family. I’ve gone out to homes in advance of the nurse only to find that family just needed to know that the symptoms are normal and reassurances that they are doing everything right. There have been times where the family has said after my social work visit that they don’t need a nurse visit anymore. To be clear, I’m not in any way doing nursing work when I’m there. What I can do is assess if patient looks comfortable and there are no signs of distress or discomfort. Sometimes just hearing an outside person’s reassurances is all a caregiver needs in that moment.

Is there another nurse on the team who has a lighter load who can visit?

A good hospice organization will have a culture where staff members help each other out.

Intervention: Lead by example with your team members and provide support if another team member is “in the weeds.”

When what you give is never enough

I have to acknowledge there are patients and caregivers who do seem “needy” with time and sometimes their needs are beyond the scope of the work that we do. Patients with COPD in particular can be highly anxious and can have emotional needs. For these patients, we do need to also set time boundaries.

Intervention: Set expectations by telling a patient at the beginning of the visit how much time you have.

There are visits where you do have a limited amount of time due to another scheduled appointment. It’s best to acknowledge this for the patient or caregiver up front so that they don’t perceive that you are bored or impatient with the visit if you frequently look at your watch or the clock.

It may be helpful to know that there is patient satisfaction research that indicates that patients perceive that a provider spent more time with them if they sat down. Do you use a chair or stool in your visits?

If needs are emotional, be sure to be engaging the entire team in coordinating visits so they are spread out across the days. Utilize your volunteers to provide extra support to emotional patients and remember that telephone calls can be an intervention as well.

Show that we value the patient’s limited time

“If I’m here and you’re here, doesn’t that make it our time?” – Jeff Spicoli

Patients who are on hospice have limited energy. Caregivers can be overwhelmed and exhausted. If they’re not up for a visit, we shouldn’t force it because we need to check a box that we did our visit. There are nuances between someone declining a visit because they don’t want to bother you and declining a visit because they don’t need or want it.


• Psychosocial support staff should always ask for permission to visit with patient, whether they are in a facility or in a home.

• Always ask for permission to visit with caregiver. If a caregiver says it’s not a good time because they have a hair appointment, celebrate that they are doing self-care.
Also, patients or caregivers may want a visit to end before they tell you. Always assess nonverbal behavior to see if they’re talking because they want to or if they are just being polite.

Sometimes patients or caregivers say no to a visit because we are vague with the request. They may be more open to us visiting if we clarify how much time we plan to spend and the purpose for our visit. The more information they have with the inquiry, the more likely they are open to meeting with us.

Here are some of my favorite quotes on time:

Better three hours too soon, than one minute too late.
William Shakespeare

A man who dares to waste one hour of life has not discovered the value of life.
Charles Darwin

All that really belongs to us is time; even he who has nothing else has that.
Baltasar Gracian

The bad news is time flies. The good news is you’re the pilot.
Michael Altshuler

If not now, when?

Lizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio and regular contributor to Lizzy authored a book of happy hospice stories: Somewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience. Lizzy is best known for bringing the Death Cafe concept to the United States. You can find her on Twitter @LizzyMiles_MSW.

Photo credits: 
Cover image uses photo from Jon Tyson via Unsplash
watch via Wil Stewart on Unsplash

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