Q&A with Hospice and Palliative Care Nurse, Susan Cox, RN, MSN, CHPN speaks with Susan Cox, RN, MSN, CHPN, Chief Clinical Officer for Hospice and Palliative Care of Greensboro. Susan has more than 30 years of experience in nursing and is the president of the Board of Directors for the National Hospice and Palliative Nurses Association.

Below she explains the differences between hospice and palliative care and how to get started in the career.

Q: What is your current position?

Eight years ago I started with Hospice and Palliative Care of Greensboro as a home care nurse, and for three years, I did direct patient care and home care. I loved it. It was exactly where I needed to be. After those three years, our organization decided to embark on a new project with a palliative care consultation team in collaboration with the local health system as well as long-term care facilities, and they asked me to consider applying [to be] the director of the palliative care program. I accepted that position in 2005 and then was promoted and have been serving as the [chief clinical officer] since February of this year.

Q: What services does Hospice and Palliative Care of Greensboro offer?

We provide hospice home care services, and hospice services in long-term care, assisted living and independent living facilities. We have a 14-bed, free-standing, in-patient hospice facility. We have a Kids Path program, which mainly through home health services and CAP/C services provides care for about 35 to 40 kids. We have a counseling and education center that not only provides bereavement services, but also education and community counseling. We also have a palliative care consultation service for in-patients in the local health system as well as long-term care facilities.

Q: There are a lot of misconceptions about hospice and palliative care? How would you describe hospice care? Palliative care?

My best explanation is: every hospice patient can receive palliative care, but not every palliative care patient is eligible for hospice yet. Palliative care is comfort. It is providing symptom management. People can get involved with palliative care upon diagnosis of a life-limiting illness even though they may have years to live. Palliative care works with patients and families to make sure patients' symptoms are under control while they're going through whatever treatments that are planned. Then, when the physician thinks in his or her medical opinion [that a patient has] about six months or so left to live, we bring hospice in.

Q: How did you get started in this field? What kind of preparation does someone pursuing this career need?

Very few nursing schools provide a lot of exposure to hospice and palliative care. If someone is straight out of nursing school, it would probably not be the best choice for them to begin their career providing hospice care. You have to be extremely autonomous. You have people you can call, but you don't have a nurse in the room next to you for help. We look very carefully at life experience, what nurses have done in the past, and what exposure they have to hospice.

Some of the [nurses] that come to hospice are the ones that have been out there working in acute care, and they've gotten very frustrated about what they feel is futile care that is causing more pain and grief for the patients and families. [In hospice], you establish a relationship, you know what the goals are for that patient and family, you help them achieve those, and you make sure their symptoms are under control.

Q: What is an average day like for a hospice/palliative care nurse?

For a nurse who is caring for hospice patients, whether it's in a long-term care facility or in their homes, the day usually starts out with planning visits. When [hospice nurses] start their days out, they may be making a visit by themselves, they may have scheduled a joint visit with a social worker, or they may be making a visit with the hospice physician.

A normal visit probably lasts 45 minutes to an hour. That's time in the home with the patient and their family. [Nurses] are always assessing vital status and pain status. They're checking medications. One of the big things our nurses have to do is document [decline] of the patient. You have to document small things because Medicare will say, "If they're not declining, then they are really not hospice eligible."

[Nurses] make approximately four maybe five visits a day.

Q: Are there any specific traits that work well in this career?

You really need to have excellent critical thinking skills. You have to be able to look at the big picture. You're not going in and just looking at one system. You really need to have good assessment skills.

Q: What are some of the challenges nurses face working in hospice/palliative care?

It can be a challenge to not really know what you're walking into with each visit. You can walk into crisis situations, and you have to be able to think quickly. You also need to know when you should call someone back at the office and run [a situation by them].

Q: What kind of changes have there been in hospice and palliative care in the last few years?

Two years ago we had a total change in our conditions of participation for Medicare. The RNs are considered the case managers. They work as the team leader in a way. In the long-term care facilities, we should be providing different services that the patient would not be able to receive. There should not be duplication of service.

At our hospice, over 90 percent of our patients are Medicare patients and we get a per diem from Medicare. There have been [some changes] on the government level. We're looking at cuts in [per diem rates] in the next five to 10 years. Cuts affect us greatly.

Q: What do you see for the future of hospice and palliative care?

In the past five years or so, there has been a great increase in hospice programs. [The government] is really looking to make sure that [care providers] are meeting regulations and doing things properly. They are looking at patients that have long lengths of stay. Why do you still have them under the hospice benefit? Are they declining? Can the physician show that they still have a six months or less prognosis?

I would say just from looking at statistics, hospice should be involved in about 60 percent of the deaths that are occurring. There are still patients out there that never get referred, get referred too late, or are admitted to hospice for only a week or two. The family and the patient do not receive the full benefit of everything that hospice can provide. I hope we see an increase in [palliative/hospice care]. It's a positive thing.

Q: How do you deal with the deaths of your patients? Many people say they couldn't go into hospice care because it's "too depressing." How do you maintain your sense of joy?

You have to be able to take care of yourself as well. You have to be able to think, "I know my patient is going to die. My goal is to make sure that they are comfortable." Nurses have to know that they need to take time off to be able to take care of themselves. They need to be able to talk through rough cases. We focus quite a bit on compassion, fatigue and self-care and make sure that people are not burning out.

Q: Any other recommendations for aspiring hospice/palliative care professionals?

If your hospital has a hospice or palliative care unit, consider working there for a little while. Consider doing a ride along with a hospice nurse. We've done that before with people who have applied to work for us. We will set them up so they can come along with one of our nurses to see what a typical day is like. Pick up the phone and call somebody at your local hospice. When I came to work for hospice, I will fully admit that I had no idea about everything that hospice did.

I think it's important for schools of nursing to have some type of a course in palliative care. I firmly believe that every nurse provides palliative care no matter where they're working. Every nurse at some time in his or her career deals with someone with a life-limiting illness.