Hospice Care: Interdisciplinary Roles, Cultural Considerations & Pain Management

Medical Director

• Holds a Doctorate of Medicine (MD) or Osteopathy (DO)
• Overall medical responsibility for hospice patient care program
• Functions as consultant—does NOT replace the patient’s primary health-care provider (HCP)
• Duties:
  • Certifies hospice eligibility in consultation with the Interdisciplinary Team (IDT)
  • Mediates between IDT and the HCP
  • Oversees and verifies that all ordered care is palliative rather than curative

Nurse Coordinator & Hospice Nurses

• Nurse Coordinator (Registered Nurse)
  • Performs initial assessment & admits patient to hospice
  • Co-develops Plan of Care (POC) with IDT
  • Ensures POC adherence; assigns nurses & aides; schedules meetings; clarifies payment sources
• Hospice Nurses
  • Coordinate services among HCPs, pharmacists, dietitians, PT/OT, social work, clergy, CNAs, volunteers
  • Must be skilled in compassion, teaching, adaptation, and especially in pain & symptom control

Social Worker

• Conducts psychosocial assessment (blend of psychological & social factors)
• Provides:
  • Community-resource linkage & insurance paperwork assistance
  • Emotional support, grief counseling, caregiver support
  • Communication facilitation when needed
• Operates under HCP direction & within the POC

Spiritual Coordinator

• May represent any faith tradition; acts as liaison between spiritual community & IDT
• Responsibilities:
  • Completes spiritual assessment; integrates spiritual goals into POC
  • Locates desired spiritual assistance if none exists
  • Helps manage fear, unfinished business, reconciliation, prayer, spiritual healing
  • Assists with funeral planning, officiating services, & family bereavement support
  • Serves as a cultural resource

Cultural Considerations in Death & Dying

• U.S. hospice must address multicultural needs; compassionate, empathic care bridges cultural gaps
• Essential cultural-assessment factors:
  • Religious beliefs
  • Primary decision-maker & decision-making process
  • Dietary preferences
  • Preferred language & need for interpreters; provide written materials in preferred language
  • Support-measure preferences (e.g., alternative medicine; who may visit)
  • Perspectives on death, dying, burial, & corresponding grief practices
• All plan-of-care changes must be discussed with entire family to respect differing belief systems

Volunteer Coordinator & Hospice Volunteers

• Experienced in volunteerism; evaluates patient/caregiver need for volunteer help (especially to prevent caregiver “burnout”)
• Volunteer roles: companionship, respite, errands, yard work, reading, sitting with patient
• Ensures each volunteer:
  • Completes ≈ $30\,\text{hr}$ of training (programs vary)
  • Is matched appropriately to patient
• Medicare/Medicaid certified agencies must document that $\ge 5\%$ of total service hours are volunteer-provided

Bereavement Coordinator

• Grief-specialist professional (may also counsel)
• Assesses risk factors at admission; follows caregiver(s) for at least $1\,\text{year}$ post-death
• Provides/organizes:
  • Support groups, bereavement volunteers, referrals for complex cases
  • Counseling aimed to (1) offer support and (2) aid survivor transition to life without the deceased
  • Integrates grief support into POC

Hospice Pharmacist

• Licensed pharmacist on call for drug-related consultation
• Evaluates:
  • Drug–drug & drug–food interactions
  • Dose appropriateness, administration route & timing
• Provides education about common hospice drugs (see Table 40.3 excerpt) & titration guidance

Nutrition Consultant (LMNT / Licensed Dietitian)

• Consult available upon nurse referral when nutritional issues noted at admission
• Duties:
  • Diet counseling, meal planning, education on end-stage nutritional challenges

Hospice Aide (Certified Nurse’s Aide – CNA)

• Works under hospice nurse
• Provides ADL assistance: bathing, grooming, oral/skin care; may perform light housekeeping
• Often forms close, trust-based relationships allowing easier emotional expression by patient

Additional Rehabilitation & Support Services

• Physical Therapist (PT): transfer training, anti-cramp exercises, wheelchair fitting
• Speech–Language Pathologist (SLP): communication & swallowing support
• Occupational Therapist (OT): comfort positioning, adaptive equipment, ADL facilitation
• All ordered strictly for quality-of-life, not rehabilitation

Palliative Care & Symptom Management Framework

• Goal: optimize comfort, dignity, and quality of life through ongoing assessment/re-assessment
• Common standardized tool: Edmonton Symptom Assessment System (ESAS)
  • Patient rates 9 domains (pain, fatigue, drowsiness, nausea, appetite, dyspnea, depression, anxiety, overall well-being) on $0\text{–}10$ scale at admission and each visit

Pain Assessment Principles

• Pain is the most feared symptom; management is hospice priority
• Sources: tumor invasion, organ compression, tissue erosion, neuropathic mechanisms, psychosocial/spiritual pain
• Primary data source: patient self-report
• Numeric Rating Scale (NRS): $0$ = no pain, $10$ = worst possible; scores $\ge 5$ significantly impair quality of life
• OLD CARTS mnemonic:
  • Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatments tried, Severity
• Routine re-assessment essential; any change triggers POC revision

Pain Management Guidelines (Box 40.3)

• "It is never right for a patient to suffer pain."
• Ask every visit: "Are you experiencing any pain?" Use full assessment if “yes.”
• Pharmacologic principles:
  • Provide regular, around-the-clock dosing; add PRN doses for breakthrough pain
  • Utilize combination therapy (e.g., morphine + adjuvant) to maximize relief, minimize side effects
• Non-pharmacologic adjuncts: heat/cold, repositioning, massage, TENS, relaxation, music, acupuncture, radiation, nerve blocks

Types of Pain & Typical Treatments

Medication Selection & Titration

• Lifestyle, route feasibility, and symptom profile guide choice
• Oral route preferred for self-management when possible
• Titration: slowly increase dose until therapeutic effect reached
• Common long-acting agents: morphine sulfate controlled-release (MS Contin), oxycodone CR (OxyContin), fentanyl patch (Duragesic)
• Breakthrough pain demands rapid-acting formulations (e.g., Roxanol)
• Myth busting: addiction, tolerance, respiratory depression are minimal risks with expert monitoring

Excerpt – Common Hospice Medications & Nursing Focus (Table 40.3)

• Morphine (IR & CR): monitor pain, constipation, N/V, sedation; schedule routine doses
• Fentanyl patch: apply to clean dry skin; check for confusion/hypoventilation
• Droperidol & Prochlorperazine: antiemetics; watch for hypotension & extrapyramidal signs
• Senna: prophylactic laxative if opioids prescribed; encourage fluid intake
• Lorazepam: anxiety control; advise slow position changes, no driving
• Acetaminophen: monitor cumulative dose to prevent hepatic injury

Nursing Interventions & Patient/Caregiver Education

• Continuous cycle: Assess → Plan → Implement → Reassess
• Teach:
  • Medication purpose, schedule, side-effect monitoring
  • Pain/respiratory symptom diary keeping
  • Non-drug comfort measures
  • Recognition of escalating pain or dyspnea and when to notify hospice team
• Provide emotional support and reinforce that adequate dosing is appropriate and ethical

Sample Nursing Care Plan (Mr. B.; Metastatic Prostate Cancer)

1. Patient Problem: Pain rated $7\text{–}8/10$
   • Goal: pain $\le 2/10$
   • Interventions: regular assessment, medication compliance check, side-effect management, alternative pain modalities, pain diary
2. Patient Problem: Dyspnea (SpO$_2$ $83\%$)
   • Goal: eliminate SOB complaints
   • Interventions: assess breath sounds & effort, oximetry each visit, administer $O_2$ at ordered flow (e.g., $3\,L\,/min$ NC), position strategies, relaxation breathing, emotional support
   • Critical-thinking prompts: manage constipation due to opioids; three interventions to improve oxygenation

Ethical & Practical Implications

• Upholding dignity and alleviating suffering are central ethical imperatives
• Consistent collaboration within IDT prevents fragmented care
• Navigating cultural diversity respectfully protects patient autonomy and family cohesion
• Meeting federal volunteer requirements ensures program funding and community engagement