Hospice is a philosophy of care. It treats the person rather than the disease and focuses on quality of life. It surrounds the patient and family with a team consisting of professionals who not only address physical distress, but emotional and spiritual issues as well. Hospice care is patient-centered because the needs of the patient and family drive the activities of the hospice team.
Roles and responsibilities of a hospice team.
Physician: The physician is responsible for identifying the patient’s need for hospice and making the referral for hospice services. They are encouraged to remain involved as a member of the patient care team, and to actively participate in the hospice plan of care.
Hospice Medical Director: The hospice medical director provides an oversight of patient care and support to the hospice team. The hospice medical director attends a team conference to discuss the plan of care by assisting in establishing goals, and participating in decisions regarding patient care.
Registered Nurse Case Manager: The registered nurse case manager coordinates the plan of care with the physician and hospice medical director through initial and ongoing nursing assessments. The nurse visits the patient two or three times a week, or as needed, to ensure all distressing symptoms are effectively managed and that patient and family needs are being met. The RN supervises all care provided by the licensed practical nurse and home health aide, and coordinates care with the other members of the hospice team to ensure patient and family spiritual and psychosocial needs are met.
Social Worker: The hospice social worker provides initial and ongoing psychosocial assessments of the patient and establishes a psychosocial plan of care. The social worker normally sees the patient once or twice a month to provide emotional support and ensure patient and family psychosocial needs are being met. The patient/family or any member of the hospice team can request additional psychosocial visits as needed. The social worker can provide assistance to the patient and family such as helping the patient with a Do Not Resuscitate (DNR) order, assisting with finding community resources, and making arrangements for nursing home placement or transfer to inpatient care facility. The hospice social worker can also provide counseling to the patient or family in times of crisis.
Chaplain: The hospice chaplain provides spiritual support to the patient and family as needed. The chaplain visits once or twice per month or more often if requested. The care provided by the hospice chaplain can address religious issues, however the focus of care is more spiritual, in nature, than religious. Care by the hospice chaplain is non-denominational.
Bereavement Counselor: The bereavement counselor not only supports and guides the family through the bereavement period after the loss of a loved one, but can also help the patient deal with the grief associated with declining health. The bereavement counselor can provide bereavement services to the family up to a year, or longer, after a loved passes.
Home Health Aide: The home health aide assists the patient and family with personal care needs and light housekeeping. They also teach family members the correct and safe method for providing personal care to the patient. The home health aide supplements the care provided by the nurse case manager.
Hospice Volunteer: The hospice volunteer provides companionship and support to the patient and family. All hospice volunteers are required to attend volunteer training at the hospice. The volunteers frequently perform needed errands and light housekeeping for the patient and family.