Sunday, February 1, 2015

The End - Hospice Information for Writers with Lara Nance


Today, we are visiting with Lara Nance. Lara has been
a nurse practitioner for 10 years in a variety of settings. She mostly works with geriatrics and also works with a hospice company. She's had a lot of experience with death and dying and was certified as a trainer for the palliative care program for nursing homes, as well as being a fellow writer.

Lara,  can you give us a tutorial on hospice? Under what circumstances does someone come under hospice care?

Lara -
Hospice was originally developed by Medicare specifically for cancer patients so they could be in the home setting in the end stages of the disease and have a more comfortable, dignified death.

Then over the past years, it has expanded to cover any type of illness where a person's life expectancy is likely to be six months or less.

Medicare funds the program. It's a plus for them financially because it is less costly for patients to stay in their homes and receive care than to be in expensive hospital or nursing home settings.

It's better for the patient because they can be more comfortable in a home setting as institutional settings can be very stressful with the level of activity and noise.

Hospice provides medicines that are for the comfort of the patient, equipment for comfort, such as hospital beds, and in home care with aides and nurses providing bathing, etc and medical care for issues not related to the person's primary diagnosis.

They will provide what is called a "Comfort kit" that contains liquid morphine for respiratory distress and pain, Ativan for anxiety, a drug like haldol for agitation, and atropine drops for increased secretions. The family is trained to administer these drugs appropriately as needed.

Hospice also provides a social worker to help the patient and family deal with issues of dying. They also provide a chaplain for spiritual needs.

My role as Nurse Practitioner is to visit patients every 60 days to see what their current status is and help determine if they continue to remain in the program.

It's possible for a patient to be discharged from hospice if they improve and their 6 month life expectancy changes. I've seen this happen, so a person doesn't necessarily die in hospice. Sometimes the extra care they receive improves their condition and allows them extend their lives. This is usually for the non-cancer illnesses.

All in all, hospice provides extra hands on patient care and support for the patient and family that will allow them to stay in a more comfortable setting in the end of their days.

Fiona -
Just recently, my father-in-law died from cancer. We are very grateful that he is no longer in pain. The doctors had been suggesting that he be in hospice for months prior to his passing. But my mother-in-law put it off until the very last few days. 
I imagine that for her, deciding to enter into the hospice process was like giving up. Do you see resistance to the process in either patients or their families? 

Lara -
Oh yes, that is the most frequent objection we see. Because of the old use of hospice strictly for cancer patients the life expectancy could be pretty accurately predicted. So when a cancer patient was given the 6 month time frame, it was usually a death sentence.

Now, with all sorts of illnesses, the predictability of end of life is less precise. Usually when I take time and explain all this to the family, it helps. I tell them that it actually means more care for the patient. They can change their minds at any time if they don't want to stay in hospice. Also, I let them know that there have been times when patients come out of hospice. Once they understand the whole concept, they are more accepting.

There are also time when the family accepts but they don't want the patient to know. We can deal with that and just provide the care without mentioning the word "hospice" in front of the patient.

I've also heard people say that they heard hospice uses the medicines, like the morphine to kill people, or to make them die sooner. So I have to explain the proper uses of morphine in more detail.

Usually, when a healthcare provider takes the time to explain, the objections can be dealt with. When hospice is mentioned but not explained, it can be a problem. I try to start these conversations with families and patients before it is imminent. People need to make end of life decisions before they are at the end. And they need to make their wishes known.

Fiona -  

As you are engaged in reading/viewing plotlines that include the process of death and dying -- when it is not a trauma-induced death but an illness -- what issues do you see in the writers getting the scene right. Granted, I just asked a very difficult question because I'm asking about generalities in a very personal moment.

Lara - 
I just watched a movie called, The Judge. It's an awesome movie. But the end was all wrong. The Judge, Robert Duvall is dying of colon cancer. He and his son, Robert Downy Jr. are in a boat fishing. First of all, he is not thin or wasted, which would be expected at end of life for this sort of patient. Duvall is acting as if he feels fine and is actively fishing. His son turns to cast his line, and when he looks back, his father is slumped over dead.

A person with a terminal illness typically goes through a sequence of events. They reduce their intake of nourishment over a period of time and lose weight, then they will usually go through a few days of not eating or drinking at all. During this time, they may not be aware and may appear to be sleeping or dozing. They may have periods of anxiety or agitation. They may have a build up of secretions that cause labored and noisy breathing. Pain issues may increase, and there may be periods of apnea, where their breathing stops for a few seconds.

Using the morphine, atropine and ativan help slow the heart rate to normal, ease respiratory efforts and clears secretions. This makes the patient comfortable. They may move in and out of alertness until they finally die.

In the case of the movie, to have a sudden silent death like that made it unbelievable for me. Even with a massive heart attack or stroke, there would at least be a peep from the guy before he died! Anyway, that's one example. A majority of the deaths I see from terminal illnesses in hospice follow a specific pattern as mentioned above.

Also, at end of life, the hands and feet of a patient become cold and may have purple mottling as the heart pumps less and less to the extremities. That's one of the ways we can predict time of death.

Fiona - 

It is a tradition on ThrillWriting to ask our guests to tell us a story about how they got their favorite scar and if somehow you have survived without a scar up to this point then a harrowing story.

Lara -
Well, I only have one scar, and it's not a very thrilling story. LOL. 

It happened when I was a teenager. My cat had gotten into a closet that had a lot of folding chairs in it. The chairs shifted when she was crawling on them and one fell on her and she let out a blood curdling howl. I ran to the closet and opened it then tried to lift off the chair. I guess she was in shock and afraid because she attacked me and bit my hand, clamping down just below my thumb. Caused a pretty good gash, and I had to go to the hospital. She was okay, though.

Fiona - 
When you are not helping people with their end of life comfort, you are writing. Can you tell us a little bit about what you write and your newest book, A Coma with Dragons

Lara - 
Yes, my other full time job...LOL. I love writing and hope to do it full time soon. I have over a dozen books and short stories published in a variety of genres from mystery to paranormal romance, to steampunk adventures.

My latest book, A Coma With Dragons, is a fantasy with romantic elements. I call it, When Sleeping Beauty meets Game of Thrones.

In two of my books have a nurse practitioner as the heroine and I'm able to throw in some of my real life experiences there. They are: Memories of Murder and Dealers of Light.

Fiona - 
My last question - What is it like to be a hospice nurse, how does one cope with death being the work day - every day? 

Lara -
Nurses tend to help each other with these issues. We are a giving and nurturing bunch and seems to be in our DNA to be able to cope with the death and dying.

The issue that hits me the hardest is not the folks at end of life in their 80's and 90's that have had a good life. It's the people like my ALS patients who are in their 40's and 50's who can no longer move except for blinking an eyelid. They have spouses that are caring for them in their homes and seem completely hopeless and filled with despair. I have a hard time after visiting them.

You just try to do the best you can for the patients while they're here and make life better for them. That's all you can do.

For me, writing helps take me away from the harsh realities of my profession. I think other nurses have similar outlets as well. 

If anyone has any questions about nursing stuff they can e-mail me through my website: Happy to answer!

Fiona - 
Thank you so much for sharing this information with us Lara. 

Thank you so much for stopping by. And thank you for your support. Cheers,When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.


  1. Hi Fiona, I've followed your blog for years. I am a writer, also hospice physician for many years so I wanted to comment on the history of hospice. It was actually started by Dame Cicely Saunders - St. Christopher's Hospice in London. Many countries now embrace the concept of hospice and palliative care and I've included a link for reference - In America, the care is covered by Medicare but it is different in all countries. I want to take a moment to express the inspiration, strength, dignity and courage we have the privilege to experience while working with patients. I encourage everyone to volunteer and join a writer's group that helps to memorialize the many lives we are honored to touch. Writing helps not only patients and their caregivers, but the many clinicians that reference hospice in their fiction as well as an outlet for strength.

    1. Thank you so much for this information and your perspective, Linda. I agree storing those memories is such an important thing for us to do.


  2. I do not know if there are specific rules on hospice in the USA or if states make the rules. My wife works in care facility that offers rehabilitation or hospice. The hospice section is separated and the average time for patients is less than twenty-one days.

  3. Blessing of Hospice for Writers, @LatelaMary ... My friend Pastor Sandra called me one Sunday morning. Her mother was at hospice, and she asked if I'd stop in, since she herself would be late. When I arrived, one of the nurses led me to a quiet room, explained that Mrs. Y had passed away within the hour. Sandra would arrive in an hour. The nurse asked if I wanted to see my friend's mother, so I sat with this lovely aged woman, introducing myself silently, as we had never met. I prayed for her, having both impromptu prayers come to mind, as well as Psalms and Gospel verses from my Bible. Then I left, so that the staff could finish their preparations. .. I am quite familiar with Hospice of Branford, CT, a wonderful facility, the first hospice site in the U.S., founded by Cicely Saunders, who came to U.S., to Yale, to implement a model after her hospice in G.B. Several of my aunts and uncles went there as they reached the end of their final illness, cancer mainly. Hospice provides excellent palliative care, powerful medication to treat pain, alternative healing modalities. It also provides an open door wherein loved ones may come at any time to sit with a patient. If a patient improves and can go home, they may return if/when they relapse. Hospice provides support for families, and after death counsels them.... My dear Aunt Mary died at Hospice. I recall her asking, "Why does it take so long?" and wordlessly I kissed her cheek. Aunt Florence was with her when she took her last breath (I had to be at work). The fact that Mary did not die alone, that she was surrounded by loving staff, by her dear loved ones, brought great solace during our time of mourning.... The first American Hospice. was opened in 1974 in Branford, Connecticut. Spanning four decades as the country’s first hospice, The Connecticut Hospice, Inc. is also the first palliative teaching hospital earning the national Joint Commission’s first “Advanced Palliative Certification.” Their 100 percent compliance rating reflects a commitment to the highest ratio of care between nurses and patients in the country. The nurses complete the Norma F. Pfriem International Hospice and Palliative Care Nursing Program....Connecticut Hospice uses many modalities to address the needs of patients with an irreversible illness.While the control of physical pain and other physical symptoms is the central and primary concern for caregivers, it is not the only priority. The patient with an irreversible illness suffers from an array of emotional, spiritual, social and financial problems. The rationale for their Hospice caregiving staff is that it is impossible for any discipline to provide the range of services required. Through the team approach, Hospice helps patients and families attain optimum quality of life – with physician and clinical pharmacy rounds daily, house calls by physicians and medications delivered to your home. Connecticut Hospice serves anyone in need — regardless of ability to pay. They provide inpatient and home care which empower the living to live fully and their family to see them as a person of mystery, beauty and strength. Your contributions also pay for free care we provide at the end of life, so that the Hospice patients and their families are not additionally burdened. Info from © 2014 The Connecticut Hospice, Inc.
    HOSPICE INFO FOR WRITERS ~ For answers to Frequently Asked Questions from Branford Hospice go to:
    For the complete blog posting, see @LatelaMary | July 9, 2015 at 10:57 am. Fiona, thanks for inviting me to participate. Mary Ellen.