by Brenda Morales – Pico, M.D. Candidate, University of North Carolina School of Medicine
I attended the hospice interdisciplinary meeting on my first afternoon of the hospice experience, and one of the first nurses to report stated that her patient was transitioning. My initial thought was that her patient was being transitioned from his home to an inpatient hospice unit. I had learned that morning during my time with a palliative medicine team that patients can receive both palliative care and hospice care in a number of different settings, from the hospital, to skilled nursing facilities, to inpatient hospice units. However, I soon realized that the word “transitioning” has a different and very specific meaning in the world of hospice care. Transitioning is the beginning of the final stage of dying, the confluence of signs that indicate that a patient is approaching death within a few days.
The following day, during my time at Levine & Dickson Hospice House – Huntersville, I was able to round on several patients with one of the nurse practitioners. Her patients were all in different stages of the hospice experience and in different phases of the dying process. She pointed to the signs that one patient had recently begun transitioning — he had stopped eating and was now sleeping for long periods of time. In fact, on the day that we visited him, we were unable to rouse him. During our exam, we were only able to elicit a grimace from him.
I was not aware of all of the signs and symptoms of the transition to death before my hospice experience. In medicine, it is very often so difficult to predict how much longer patients have before they die when their prognoses are months to years. However, once they have entered the transition phase, the nurse practitioners are reasonably able to predict the number of days a patient will continue living, often based on the last time he or she was able to take anything by mouth.
I was surprised by how thoroughly the nurse practitioners assessed and examined each patient. They were truly attentive to a myriad of symptoms from pain to nausea to agitation. The management of these symptoms seemed complex, especially for the patients in the inpatient hospice unit, who had been transferred there because their symptoms could not be adequately managed at home. There truly is both a science and an art to helping patients transition – transition from their homes to skilled nursing facilities, from palliative care to hospice care, from their homes to inpatient hospice units, and finally from life to death.
There is also an art to helping the patients’ families transition. I was able to sit in on two different family meetings during my hospice experience. One was a discussion about goals of care with a woman who was receiving palliative care in a skilled nursing facility following a hospitalization. The other was with the family of relatively young patient who had just been admitted to Levine & Dickson Hospice House – Huntersville the night before. In both meetings, I was struck by the patience and openness of the providers as they answered the family members’ questions and guided them through difficult decisions. It was clear that their roles as providers were not just to transition patients comfortably from life to death, managing their symptoms medically, but to transition patients and their families to a sort of spiritual or emotional comfort.
As I transition from medical student to physician, I am certain that I will benefit not only from the greater understanding of hospice and palliative care that I have gained through this experience, but also from the examples of truly wonderful and holistic care that I encountered during my time with palliative medicine and hospice care.