Four weeks ago the visiting nurse agency I work at announced it was closing. Since it was a job that I absolutely loved, this was devastating news. After the shock, the anger flared and the “what ifs” nearly drove me crazy. Now I have three more days to go until my last day. I’ve accepted the inevitable but I am very sad and it hurts to say good-bye.

My patients have had a hard time too. Some of my patients I have seen at least weekly for over four years. There is the ninety year old that stands by the window watching for me to arrive. One of my patients tells me that she talks to me more than she talks to her son and daughter. She makes it clear that she doesn’t want any other nurse ever taking care of her. There’s also that new Alzheimer’s patient that is just beginning to get used to me coming to see her. There is still so much more I want to do to help her.

This week, however, is not about implementing new plans of care, getting my patients through the lonely holiday season, or recertifying them for another 60 days of care under Medicare. Instead I am saying my good-byes.

Today there was one hard good-bye. The wife of a man with advanced parkinson’s disease started crying when she walked me to the door. When I first started seeing her husband, she was uneasy about people coming in to their home to help her care for her husband. That was two years ago. Over time, she became comfortable with the visits and told me that she thought of me as their friend. I walked away from their house in tears.

This was all getting to be too much until I remembered one thing: I may be saying good-bye to some very special people which greatly saddens me but I know that in my next job there will also be the opportunity to make those incredible human connections that touch my heart. That is one of the best reasons to be a nurse!

]]> http://nursetalk.wordpress.com/2011/12/14/forced-to-say-good-bye/feed/ 0 cwall34 another sunset http://nursetalk.wordpress.com/2011/11/28/the-four-year-plan/ http://nursetalk.wordpress.com/2011/11/28/the-four-year-plan/#comments Mon, 28 Nov 2011 01:45:00 +0000 cwall34 http://nursetalk.wordpress.com/?p=223 ]]>

My nursing career seems to be on a four year plan. I work four years at a job then get laid off. This has now happened to me three times in the past twelve years. There’s definitely a pattern going on here.

First there was the geriatric internal medicine office where I worked as a manager. Restructuring took place and I was left without a job. I was traumatized, an emotional wreck. “Since when do nurses get laid off?” I asked myself over and over.

I recovered from this devastating experience by taking a job in the medical review department at Medicare. Not my favorite job but it was less stressful than what I had experienced in the office setting. Salary and benefits were good. Four years passed and word was out that the office would be closing if the contract was lost. The contract was lost but I jumped ship before it was a done deal. The good news was that I found the perfect job. I became a visiting nurse.

The next four years working for a small visiting nurse agency in the town where I lived were incredibly fulfilling. I was back to taking care of patients and was loving every minute of it. The salary was so-so, the benefits decent. I had good supervisors. For the first time I worked as a union employee which gave me a feeling of being protected. I could see myself doing this work until I retired. But I forgot…four years had passed and it was time for all good things to come to an end. And it did last week when it was announced that the agency was closing.

So once again, I am going through the emotional experience of being laid off. This time is pretty tough since there are patients that I have become very close to and I can’t seem to reconcile myself to saying good-bye to them.

Early in my career, I worked at a place until I decided to leave. I lasted sixteen years at my very first job, thirteen at the next. It was a time when nurses didn’t get laid off, contracts weren’t lost, health facilities didn’t close.

Funny thing is that now I am just four years away from retirement so if my next job plays out right it should take me right to the end of my career. But who knows in today’s job market if my career will suddenly shift to a two year plan or even a one year plan. No job, not even a nurse’s, is secure. I can attest to that.

“When I think about all the patients and their loved ones that I have worked with over the years, I know most of them don’t remember me nor I them.  But I do know that I gave a little piece of myself to each of them and they to me and those threads make up the beautiful tapestry in my mind that is my career in nursing. ” ~Donna Wilk Cardillo, A Daybook for Beginning Nurses

As a home-care nurse, it upsets me…..

 to see an elderly woman living alone abandoned by her family with only the intermittent visits of a home health care professional to brighten her day and tend to her needs.

 to see a vibrant, energetic man felled by parkinson’s disease be no longer able to walk safely across the room or dress himself.

 to see a man whose only words are “yes”, “no”, and “there, there”. Who knows what he really wants to say?

 to see a ninety-five year old lady living on her own frustrated by a system that suddenly takes away seventeen dollars of her food stamp money due to state budget cuts.

 to hear that my elderly patient’s doctor didn’t listen to her when she told him about her pain. “That’s just old age” is her doctor’s usual reply.

 to hear my senior patients say that every day is the same for them now. Not like the old days when they played cards with friends, cooked for family, or went dancing.

 to hear that some children won’t spend a dime or lift a finger to help their elderly parents.

 to hear an arthritic old lady with congestive heart failure say that she wishes God would just take her because there is no good reason for her to be still here.

Two hours working on paper work and I am beat!

Visiting patients is the easy part of my day. The part that gives me the greatest satisfaction and reaffirms my choice of career. The paperwork doesn’t. I’ve read that paperwork is one of the top four reasons nurses leave the clinical setting. Is that surprising?

Paperwork takes time. My typical day starts at 8am. I carry a laptop when I make my home visits but I try to do most of my computer work outside the patient’s home because I value my patient-nurse relationship. A computer gets in the way. I work through lunch documenting the care I gave in the morning. I make more home visits in the afternoon and I’m back in the office about 2 or 2:30 pm. And then begins the hours of paperwork.

Our software package sets up our documentation template to meet the Medicare rules and regulations called OASIS. When the patient is a new one or has just returned from the hospital, is being recertified or discharged, the OASIS template is longer, more demanding. Built into the software program is our clinical note (“nurse’s notes”). In years past, nurses often used a SOAP (subjective/objective, assessment/plan) format. Now I’m writing my note to meet the demands of the Medicare reviewer. A typical note may begin “Skilled nurse visit where the primary focus was on skilled assessment and observation. Minimal education was done at this visit”. I’m writing for the insurance reviewer.

In my line of work, paperwork includes plans of care for home health aides, review of doctor’s orders, faxing updates and a summary of medication interactions to primary care physicians, to name a few.The bane of my day is the feedback sheets we get reviewing our documentation. Every time we do a new, returning, recertified, or discharged patient we get reviewed. And that happens a lot. Like a teacher reviewing a paper you turned in, the supervisor reviews the documentation and always finds something wrong. Her job is to function like a Medicare reviewer, challenging every detail of the documentation you have done, always expecting that it can be done better but never finding that it was. For a senior nurse it is necessary but degrading experience. For a perfectionist like me, it is devastating.

It is nearly 6 pm when I am done. The fingers are cramped. The mind is overwhelmed. The joy of helping people sick and in need is diminished. But then there is tomorrow and the first person I see gives me a hug because she is happy to see me and it all is worthwhile again..for awhile.

 Public Act 09-5 Section 66 is the statute that mandates the 15% copay. Here is how it works:

 The client has 30 days from the date of the bill to remit a payment. If the next month’s bill is ready to go out and no payment has been received on the previous bill, the client will get a notice informing them that the bill is past due and must be paid within 10 days or services will be discontinued. If there is no payment made in the 10 day period, the Alternate Care will issue a discontinuance notice and give the client an additional 10 days to remit payment. If the client pays the past due amount, they can stay on the program unless they fall behind by more than one month. Clients who go off the program for non-compliance with the cost sharing requirements may reapply for the program but services may not be initiated until they remit the full amount past due. Per the statute, clients are not entitled to a Fair Hearing for a discontinuance related to non-compliance with the cost sharing requirements. The statute does not allow for any hardship exceptions under the cost sharing requirement.

 So it seems that the senior pays the copay or they are out of the program with no appeal rights or hardship exceptions. Outrageous!

 Let me tell you about Bill (the name and some of the facts have been changed to protect his identity).

Bill lives alone in a low-income housing project in a neighboring town. I started to see him about two years ago when his diabetes was out of control and he needed to start insulin. While he learned how to give himself shots, he could not remember to do it on a daily basis. By taking his insulin eradically, his blood sugars were all over the place. One time he even took two doses of insulin in one day. Thankfully he survived without harm. It was evident that he had significant short-term memory problems that made living alone a challenge.

 Bill’s wife died years ago and there were no children. He only has one living relative, a brother who is in a nursing home in Florida with advanced Parkinson’s disease. Bill is all alone except for his nurse, his home health aid, and his homemaker paid for by the Connecticut Homecare Program for the elderly.

 We have worked hard to give Bill the support he needs so he can remain safely in his own home. In the beginning, his personal hygiene was compromised by his memory problems. A health aide now bathes him. A homemaker launders his clothes and keeps his home clean. He couldn’t remember to take his pills so we got him a locked medication box that alarms when it is time to take his pills. We have set up a plan to provide someone to remind him every day to take his insulin that I draw up ahead of time. We even have the weekend nurse call him to remind him to take his insulin and stay on the phone until he takes it. He has not required hospitalization once since we have been seeing him. He is safe. His needs are being met and he gets to stay in his home.

 The monthly copay that he will be expected to pay as of January 1 is about $243 a month. I’m doubtful that he will be able to pay it. What will happen then? He can’t remember to take insulin or his pill on his own without our help. I can only imagine that he will end up dead from too much or too little insulin or require frequent hospitalizations to keep him stabilized. Ultimately he may need to go on Medicaid so he can be placed in a long-term facility. That seems to be more costly to the state then paying for the kind of services he is getting in his home now.

 Bill is just one of the many effected by this statute. As a registered nurse, I am real worried. Worried about Bill. Worried about all the elderly on this program who may think they will be safe if they choose to reduce their services because they want to save money. We know they run a great risk when they do that. Maybe the copay will work for more people than we know but there will definitely be hardship cases. They need to be heard.

• managing those leaking legs
• preventing cellulitis
• reducing edema
• encouraging compliance
• getting those compression stockings on

I’ve seen patients who have baby diapers wrapped around their legs to catch the fluid leakage. I’ve seen their slippers so sopping wet that their feet look like they have been in water for days. My own mother had to keep plastic bags under her legs to protect her furniture.  The clear fluid just drips and drips. So the challenge is to contain the fluid while other treatments are being done to reduce the lymphedema. I’ve wrapped legs with thick dressings secured with a gauze wrap to absorb fluid. Most of the time the fluid won’t stop, won’t stop dripping all over the place until the treatments start working. In the meantime, there is the risk of infection.

Cellulitis is a common complication of lymphedema of the lower extremities. The moist skin is a perfect medium for infection. Many of these patients already have underlying diseases like peripheral vascular disease or diabetes that makes the risk of infection even greater. I had one patient who had a thick layer of pus across her grossly edematous legs. Only intravenous antibiotics will bring that kind of infection under control.

The biggest challenge is to reduce the edema. Some patients need to go to a wound care center for treatment of the open wounds that develop. The wound care specialist can direct the care. Since I work in the home, I carry out the doctors orders whether it be wound care or edema-reducing interventions. I’ll see the patient daily to wrap the legs, apply medicated dressings, assess the skin, and coach the patient to follow the instructions that will bring relief.

Some patients will do everything they can but I have had others who have a hard time complying. They just don’t get it especially the need to keep their legs up. Elevating the legs forces the fluid out of the legs and into the circulatory system. This is a crucial part of the treatment. Some patients don’t have nice recliners to get them into the right position. I’ll have to show them how to improvise. I had one woman who just couldn’t tolerate elevation. She said it hurt her so she kept her legs down and they got worse and worse. She ended up hospitalized.

The best and worst part of lymphedema care is the application of compression stockings. I don’t care if they are compression wraps, stockings, or a brace, they are all tough to get on. You have to be physical fit to do it! Many of my patients are elderly and find it beyond their strength or ability to do. That’s why I’m there. I get the compression treatment on…even if I have to pull, tug, and use all my strength to do it. It is the only way. And what a pleasure it is to see the legs begin to reduce in size day after day.

That is the gratifying part of lymphedema treatment. You first see a patient with enormous, dripping legs. They may have infection making the legs not only wet but red, warm, and painful. The medical team forms and a plan is made. The patient learns what they must do. The legs start to reduce in size. The wounds heal. The skin dries up. The wraps eventually become stockings. The patient is discharged. Sounds simplistic but it does happen and when it does it feels good to have helped someone like this.

Some of these women live with their children. They see their daughters rushing around trying to balance work life with home life, a home that includes an aging parent. The patient I talked with this week said she used to help out by often cooking dinner for her daughter and son-in-law. Now she can’t.

I honestly don’t know what to tell these women. I encourage them to do things like folding laundry but that just doesn’t seem like enough to them. My heart breaks for them. Everyone wants to feel useful. I did get one woman to crochet squares that she gave to a charity organization. The squares would be joined, made into an afghan, and be given to someone in need.

Does anyone have any suggestions on how incapacitated elderly women can still feel useful? What can they do to help their families? I’d especially be interested in hearing from anyone who has lived with an elderly parent or grandparent. I’d love to be able to compose a list of suggestions that I can give to the women or their families of activities they can participate in. So please help me out if you can.

Today was a beautiful day and I was feeling well-rested and ready to get back into the swing of things. I passed a thermometer on a bank as I drove to work. It read 64 degrees. I wore a short sleeve top and didn’t bother to bring a sweater knowing it would warm up as the day passed.

I arrived at work one-half hour early so I would have time to go through my paperwork and get report on my patients. The pile of papers in my “in box” wasn’t too bad and I got through them rather quickly. Nurses who saw my patients while I was away left me written reports on their status. Most of my patients remained stable although there was one that now needed daily wound care because a blister she had broke and was raw and oozing. I had a voice mail message from a daughter of one of my patients requesting that I see her mom since she had fallen two days ago and had a skin tear on her elbow. It looked like I was going to have a busy day. That was okay. I was feeling good!

There was one patient that I wasn’t going to see today or actually ever again. Usually I saw him on Monday’s but he hadn’t been home for awhile. After falling at home, he entered rehab and didn’t do very well there. He just lost his spirit. Home was where he wanted to be and no amount of encouragement could make him accept the fact that he needed to be in-patient for at least 6-8 weeks. He never made it home. He died while I was on vacation and I went to his wake to say my last good-bye.

I noticed alot of goldenrod along the roadside. Some homes already had fall wreaths on their front door. The leaves are still green though and when the day gets its warmest, it is hard to remember that it is September and not the beginning of summer.

When I’m on the road, I have a small collection of snacks next to me. I’m not one to give in to the temptation of stopping at any number of fast food places that dot my route around town. Instead, I bring a few things to munch on. Last week when I was on vacation I went to “Whole Foods”. I found a big container of dried green beans that really seemed ideal for my daily snack. The green beans are crunchy, slightly salty, and easy to munch on while driving. I carry a bottle of water to sip on. Sometimes I have bags of dried almonds. I’ve even made my own trail mix with dried almonds, sunflower seeds, and dried cranberries.

The day flew by. My failing 92 year old woman seemed frailer and more lethargic than ever. I did wound care on two of my patients. My COPD patient required a call to her doctor to report a side effect to one of her medications she was having. One of my patients was doing just great and that made me feel terrific.

A few clouds moved in by the end of my work day but the air was still very comfortable. Maybe it will rain tomorrow. That wouldn’t be so bad since we have had outstanding weather for about a week. I logged in 38.2 miles today. And even though I went into work a half-hour early and left an hour late, I still feel the vacation spirit. I’m hoping that feeling will last at least one more day. Wouldn’t that be great!!

Mr. R. was sleeping as I approached him. I called to him and his eyes fluttered open. He took my hand and held it close to his chest. I heard him whisper “I’m not good Chris”.  He’s hard of hearing so I had to lean close to talk to him. I tell him how I miss our Tuesday morning visits. I ask him if he is eating and he replies no. “Would you like a drink?” I ask him and he shakes his head “yes” in reply. I hold the milk carton so he can sip the straw that sticks out of it. He begins drinking and soon finishes it. I decide to really push the limits by filling a spoon with ziti and sauce and offer it to him. I apologize that the sauce isn’t as good as the sauce his mother used to make but after a few bites he tells me that it wasn’t that bad. A nurse stops by and asks how I know Mr.R. I tell her that I was his visiting nurse for the past two years. She asks me what he was like at home and I tell her that he was a great guy with a big heart. I tell her how he sent a neighbor out to buy me a mother’s day card. I tell her that he sat quietly in a recliner surrounded by photos of his family. He loved our visits and visits from his big Italian family.

I have to leave since I was due at another patient’s house in a few minutes. Fortunately, my next patient lives down the street. My visit with Mr. R. was an unofficial one since he is no longer my patient. (We don’t see patients in the hospital or nursing facilities) I think of him often especially when Tuesday morning comes along. I lean down now and give him a kiss on his forehead. “I’m praying for you” I say to him. He tells me that he prays for me to. He closes his eyes as he lets go of my hand. It’s still raining out as I exit the building. The rain camoflages the tears that well up in my eyes as I get in my car and leave.