Over the 31 years in family medicine, I've had many patients reach the end of their life, one way or another. Those with a terminal diagnosis were often fortunate enough to get enrolled in a hospice program and meet some special nurses. Some of them are like angels who connect with the patient and allow nature to take its course with minimal distraction. They may befriend patients in a unique professional way. They may give back rubs or scalp massages. They may be the honest mirror that the patient needs to relate to their own struggles with the end of life. They may be the prayer connection to allow the patient to refresh their spiritual self.
The hospice team includes a chaplain, social worker and nurses. They care deeply about people at the end of life and develop special insights about their circumstances and their family members. They have to relate to family physicians and other primary care practitioners who are involved in a more distant sense with their dying patients. I'm a bit more involved than most, I'm told, since I want to be the attending physician for my patients who are "referred" to hospice. I've made house calls on most of my hospice patients. Hospice has pre-printed orders to facilitate understanding by all involved about medications and specific orders for medical issues at the end of life.
Caring for the patients at the end of life has always been meaningful to me since I care for most family members of my patients. I've had a "Families Only" new patient policy for 30 years so generations of people relate to my practice. Giving their care over to another physician at the end of life would be a violation of my commitment to our patient-physician relationship. If I've treated their life and their hearts, lungs, brains and pains over the years, the dying process shouldn't and doesn't separate us. The individual and family life cycles make more sense in the context of family care in family medicine.
For family physicians, the contact with hospice nurses is critical, but sometimes challenging since we usually don't get to meet each other face to face. We have to talk on the phone a few times to get to know each other before anything medically intense happens. We need to hear their philosophy of care and share ours. We need to share our perspective on what's medical and what's nursing and what's both. We need to know how we perceive this terminal patient and their family and their situation. Context matters. I see death as a natural process that may have some medical components and the care of the dying as having many nursing and even more family components. How do we best relate our beliefs to each other? How do we allow dying and death to be as natural as possible? How do we allow the family to follow their own beliefs and processes with the dying?
Not with "efficiency". Not with overly rigid protocols. Dying isn't smooth and predictable. At the end of life, "Love" is the treatment of choice and generally the hospice nurse is the leader with the most love. Hospice Nurses: Thank you for all you do.
What's next (should be already widely used)? Now we need the web cams and two way real time and asynchronous communication to the patient's home/bedside. We need to use social media and whatever it takes to get our best connections between hospice nurses and family physicians. The audio-visual contact will tighten the relationships in the primary care end of life team and allow more connection between patients, families, hospice nurses and family physicians. Sometimes even angels need technology to get the most heavenly results.