Wednesday, July 30, 2008

Graduating From Hospice

"So, my supervisor asked me to let you know that since you're doing so well, you'll be 'graduating' from hospice in two weeks. We're sorry, but we have to discharge you from our service."

I watched his face for his reaction to the news.

"Wow," he said. "I had no idea that was gonna happen. Do I really have to be discharged?"

"Well, based on the relatively strict guidelines, I'm afraid so. Your breathing is better, your kidney function has improved, your appetite is steady, you've gained ten pounds, and you're getting out of the house almost every day. Medicare has very strict criteria for being on hospice, and you no longer meet the criteria. I know it's scary," I continue, "but you have your family nearby, and your doctor agrees that you're doing amazingly well."

"Yeah. I have to admit, I'm feeling pretty good," he replies. "My doctor is wonderful, and you have all been so helpful. But couldn't I still have a visiting nurse once a week or so?" He looks at me plaintively.

"Honestly," I reply, "we would love to supply you with a non-hospice visiting nurse, but you don't meet Medicare's homebound criteria, and since you go out almost every day and it's not physically a burden to do so, Medicare says you don't need a visiting nurse. It's a lot of bureaucracy, really, but our hands are tied."

"I understand," he says. "But if my son and I need help with medications or anything like that, no one at the doctor's office will really take the time to help us. They're just too busy. I need someone to sit with me at my kitchen table and sort it all out."

"That's a problem many people have, and the government doesn't feel we should be able to help you with that if you're able to get out of the house and to the doctor's office. If you still feel you need help and don't qualify as homebound, you have to hire a private duty nurse, which we know can be an expense that many people can't afford."

We sit in silence for a few minutes. The dog scratches himself, the clock ticks, and a car horn disturbs the quiet summer day outside. Not many months ago, this man was told he was dying. Now, one look at his healthy coloring, calm breathing, and relaxed demeanor tells a different story.

"Well, it could be a whole lot worse," he says. "I could be even sicker than I was before, and getting ready to die. I guess a lot of people would be thrilled to graduate from hospice."

"Yeah, some people just turn it around and we're amazed at how well they do, and you're one of those people," I say. "And while we're sorry that we're forced to discharge you, we're also happy that you're doing so well. And we feel OK about it because you have such a supportive family."

"You're right. I'm lucky and blessed. I appreciate everything you people have done. I'll be OK. The doctor's right up the street, my son comes almost every day, and this dog is my really best friend." He rubs the sleeping dog's belly with his foot, and the gentle creature stretches and yawns.

"Well, your regular nurse will be back out to see you one more time next week. If anything comes up before then, just give us a call. It was a pleasure meeting you, and I'm sorry I had to be the one to give you the news." I move towards the door.

"It's no problem," he says. "You're doing your job and telling me like it is. I know I'll be OK, and when I need you again, my doctor can refer me."

"Hopefully that won't be for a long, long time," I say as I open the door, the hot summer air hitting me like a moist wall.

"Thanks again," he says.

"You're welcome. Take good care, now." We shake hands and I walk to my car.

Working for hospice, every visit has the potential to be so very different. Today, I had the pleasure of telling someone that they're simply too well for our services to continue. Next time, I might have to tell someone that their loved one has less than 24 hours to live. It can be a roller coaster for everyone---nurses, patients and families alike---and there's no telling when a sudden change might send all plans out the window. For now, this particular person gets a reprieve from the specter of death, and we get to break the good news.

The summer sun shines bright. A brief rain dries quickly, steam rising from the hot asphalt like wispy ghosts. I rub my eyes, turn on the radio, and head back to the office.

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