Stigma Around Hospice Nurses/Physicians?

[Kameha01]

So a registry CNA came in one night who signed up for assisted living. He was asked to switch to the hospice unit by my nurse supervisor, as my partner called in. I got to building a rapport with him, and he casually mentioned how he hated hospice work and hospice staff. He stated that he feels we don't do anything for the patients, and that it's just a waste of time. I like hospice since i get to fulfill needs beyond physical ones and learn stories about people's lives, but I was wondering if any other healthcare providers/people perceive hospice care like this? Will this stigma exist if I decide to become a hospice/palliative care physician?

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[gyngyn]

I like hospice since i get to fulfill needs beyond physical ones and learn stories about people's lives, but I was wondering if any other healthcare providers/people perceive hospice care like this?

I know of no physicians with the sentiments described here. It is valuable work that deserves our respect.

 

[Kameha01]

I know of no physicians with the sentiments described here. It is valuable work that deserves our respect.

@gyngyn Do you know of anyone/heard of anyone outside of the medical community that has those same sentiments?

 

[gyngyn]

@gyngyn Do you know of anyone/heard of anyone outside of the medical community that has those same sentiments?

No one.

 

[Goro]

So a registry CNA came in one night who signed up for assisted living. He was asked to switch to the hospice unit by my nurse supervisor, as my partner called in. I got to building a rapport with him, and he casually mentioned how he hated hospice work and hospice staff. He stated that he feels we don't do anything for the patients, and that it's just a waste of time. I like hospice since i get to fulfill needs beyond physical ones and learn stories about people's lives, but I was wondering if any other healthcare providers/people perceive hospice care like this? Will this stigma exist if I decide to become a hospice/palliative care physician?

That CNA was a f****** idiot. Your worries are needless.

I have a very high regard for people who work in hospice, because very few pre-meds are willing to get up-close-and-personal with our mortality.

 

[Kameha01]

That CNA was a f****** idiot. Your worries are needless.

I have a very high regard for people who work in hospice, because very few pre-meds are willing to get up-close-and-personal with our mortality.

@Goro Why is that? Being able to fulfill those emotional needs and make those connections is like my favorite part of being a CNA. Does that make me weird lol

 

[Goro]

@Goro Why is that? Being able to fulfill those emotional needs and make those connections is like my favorite part of being a CNA. Does that make me weird lol

Why is what? The CNA being a ****ing idiot? I've explained why I have a high regard for hospice work.

Weird??? Of course not! You're very admirable in my eyes.

 

[Kameha01]

Why is what? The CNA being a ****ing idiot? I've explained why I have a high regard for hospice work.

Weird??? Of course not! You're very admirable in my eyes.

@Goro My apologies, I meant why most Premeds don't like that part/would rather not do it. I understand and have seen the emotional toll up close and personal, and have even had to break the news myself a couple of times. But I thought that more people would want to work on that, because as a physician, isn't that a huge part of our future responsibilities? Sorry about being confusing before.

 

[Goro]

@Goro My apologies, I meant why most Premeds don't like that part/would rather not do it. I understand and have seen the emotional toll up close and personal, and have even had to break the news myself a couple of times. But I thought that more people would want to work on that, because as a physician, isn't that a huge part of our future responsibilities? Sorry about being confusing before.

Oh, it's because people are afraid of death, or rather, reminders of one's mortality.

A long time ago, I worked at a major cancer hospital. One day a crowd was waiting for the elevator int he basement. When the elevator arrive, there was an orderly with a gurney containing a body (under a sheet, of course).

Literally no one got on the elevator!

 

[Kameha01]

Oh, it's because people are afraid of death, or rather, reminders of one's mortality.

A long time ago, I worked at a major cancer hospital. One day a crowd was waiting for the elevator int he basement. When the elevator arrive, there was an orderly with a gurney containing a body (under a sheet, of course).

Literally no one got on the elevator!

Woah, that's a wild story lol.

I guess another question, is that ever since I started as a hospice CNA, I've sort of come to accept death as a part of life, and I try celebrating the lives of those I have cared for with them, whether it's by lending my ear to them, connecting with their family, listening to their stories, etc. Is it strange that, after doing this for so many people, I'm not afraid of mortality, including my own? I don't feel like I've become "burnt out", because I still love doing what I do and am happy ever day I go into work, but is my outlook strange/weird?

 

[Goro]

Woah, that's a wild story lol.

I guess another question, is that ever since I started as a hospice CNA, I've sort of come to accept death as a part of life, and I try celebrating the lives of those I have cared for with them, whether it's by lending my ear to them, connecting with their family, listening to their stories, etc. Is it strange that, after doing this for so many people, I'm not afraid of mortality, including my own? I don't feel like I've become "burnt out", because I still love doing what I do and am happy ever day I go into work, but is my outlook strange/weird?

No, not strange, but wise beyond your years. We love applicants like you! Send an app to my school, OK...It's somewhere west of the Missouri River.

 

[cj_cregg]

I have never encountered a healthcare worker with attitudes like this. I think most folks very much respect the work of hospice and palliative care.

I have lots of goals of care/should we transition to hospice conversations with patients and families, and will occasionally hear things like not wanting to give up/stop fighting, a desire to "do something" (presumably as opposed to doing nothing), etc from families of patients. However, I think these ideas are usually rooted in a fear of death and/or helplessness rather than stigma towards those who provide end of life care.

 

[Kameha01]

I have never encountered a healthcare worker with attitudes like this. I think most folks very much respect the work of hospice and palliative care.

I have lots of goals of care/should we transition to hospice conversations with patients and families, and will occasionally hear things like not wanting to give up/stop fighting, a desire to "do something" (presumably as opposed to doing nothing), etc from families of patients. However, I think these ideas are usually rooted in a fear of death and/or helplessness rather than stigma towards those who provide end of life care.

Yes you're right. I remember a patient in my older job who was diagnosed with CHF, and the physician wanted to put him on hospice/pallitative care. the patient later talked to me about those fears that you mention, and he felt like if he did what the doctor said, that he was "dooming" himself. Honestly, I didn't know how to respond at the time, but I definitely regret saying nothing at all. If willing to share, what would you have said to him?

 

[cj_cregg]

Yes you're right. I remember a patient in my older job who was diagnosed with CHF, and the physician wanted to put him on hospice/pallitative care. the patient later talked to me about those fears that you mention, and he felt like if he did what the doctor said, that he was "dooming" himself. Honestly, I didn't know how to respond at the time, but I definitely regret saying nothing at all. If willing to share, what would you have said to him?

I usually try to reframe the conversation as a transition in goals of care. We're not withdrawing care - we're continuing to care for the patient, just in different ways. We're not stopping the fight, we're adjusting what we're fighting for - quality of life, less pain, less trouble breathing, more time with family/at home, etc. I have also used something like "Your dad is dying from (disease). We cannot stop or control that process. What we can control is....(symptom management, allowing him to do X thing he really likes, whatever)."

Sometimes these approaches seem to work but sometimes the patient and/or family are just not ready to take that step. These work best when part of an ongoing conversation that starts very early in the disease process with a care team that is all on the same page about prognosis and the patient's values and goals, which unfortunately is not usually the case.

 

[Kameha01]

Wow, that's an amazing way to go about it. I'll definitely keep that in mind in the future. If you don't mind, what happens when they/the family keep refusing? Do you just "give up" on trying to convince them?

Also, a side note ethical question, and again, if you aren't comfortable with sharing it I completely understand: if a family does seem adamant about not going on palliative care, but it's very evident that the patient is in pain/suffering, do physicians ever try and "take away" that family's power to make decisions if the physician sees it as best for the patient?

 

[cj_cregg]

Wow, that's an amazing way to go about it. I'll definitely keep that in mind in the future. If you don't mind, what happens when they/the family keep refusing? Do you just "give up" on trying to convince them?

Also, a side note ethical question, and again, if you aren't comfortable with sharing it I completely understand: if a family does seem adamant about not going on palliative care, but it's very evident that the patient is in pain/suffering, do physicians ever try and "take away" that family's power to make decisions if the physician sees it as best for the patient?

I will say, regarding my previous responses, and you probably are already more tactful than this without having to be told - unless the physician has already told the patient they are dying and/or the patient has used that language themselves, I would probably hold off on using that particular phrasing when you are talking with patients. 1) obviously you want to be sure it is accurate lol, and 2) that can be pretty jarring for a patient to hear for the first time, and I think it is best to come from the physician in the context of a larger conversation.

If the patient and family keeps refusing, I respect their wishes. I may continue the conversation or revisit goals of care if things change in the future, but patients have the right to make their own decisions even if I disagree with them. Even under the best of circumstances sometimes people need time to come to their own conclusions and be ready to take the next steps, or they might never want to transition to hospice because of their goals, values, preferences, etc. And that's okay - my job as their family doctor is not to force them into what I think is right, it's to give them the information and support they need to make the right choices for themselves.

Regarding the second question - the physician can choose to NOT offer treatments or interventions they feel will be nonbeneficial and potentially harmful. e.g. an oncologist might say a patient is too sick for another round of chemo, a nephrologist might say a patient is not a candidate for dialysis, a surgeon might decline to operate, a GI doc might not offer a long-term feeding tube. The family/patient can refuse any type of treatment, including hospice care, and the physician doing that care anyway would essentially be assault. There may be extreme circumstances on the level of neglect or abuse where there may be a need to seek a surrogate decision maker for a patient but this is quite rare.

 

[Kameha01]

I will say, regarding my previous responses, and you probably are already more tactful than this without having to be told - unless the physician has already told the patient they are dying and/or the patient has used that language themselves, I would probably hold off on using that particular phrasing when you are talking with patients. 1) obviously you want to be sure it is accurate lol, and 2) that can be pretty jarring for a patient to hear for the first time, and I think it is best to come from the physician in the context of a larger conversation.

If the patient and family keeps refusing, I respect their wishes. I may continue the conversation or revisit goals of care if things change in the future, but patients have the right to make their own decisions even if I disagree with them. Even under the best of circumstances sometimes people need time to come to their own conclusions and be ready to take the next steps, or they might never want to transition to hospice because of their goals, values, preferences, etc. And that's okay - my job as their family doctor is not to force them into what I think is right, it's to give them the information and support they need to make the right choices for themselves.

Regarding the second question - the physician can choose to NOT offer treatments or interventions they feel will be nonbeneficial and potentially harmful. e.g. an oncologist might say a patient is too sick for another round of chemo, a nephrologist might say a patient is not a candidate for dialysis, a surgeon might decline to operate, a GI doc might not offer a long-term feeding tube. The family/patient can refuse any type of treatment, including hospice care, and the physician doing that care anyway would essentially be assault. There may be extreme circumstances on the level of neglect or abuse where there may be a need to seek a surrogate decision maker for a patient but this is quite rare.

@cj_cregg Thank you for your perspective! I love your advice and am definitely taking it to heart. If you have any advice at all, especially on hospice, I would always love to hear it. Thank you so much!

 

[cj_cregg]

@cj_cregg Thank you for your perspective! I love your advice and am definitely taking it to heart. If you have any advice at all, especially on hospice, I would always love to hear it. Thank you so much!

I think that's all the wisdom I have for now haha, and I'm just a soon to be family medicine attending who happens to enjoy palliative care and end of life care counseling, but feel free to PM if I can ever help out with anything!