Hospice Care

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					“Serving Horry, Georgetown, & Marion Counties Since 1981.”

Hospice Care
     A Guide for
    Their Families
                                     Our Mission

The Mercy Hospice staff is committed to comforting suffering persons whose illness has
progressed beyond a cure. Our goal is to integrate physical, spiritual, psychological, and
social care by offering a range of services which meet the needs of children and adults
during the final days of life.

After a person dies, Mercy Hospice continues to serve the bereavement needs of family
members, including children. Mercy Hospice provides support and end-of-life care for
persons and their families without regard to race, creed, or gender.

                                      Our Vision
                 Mercy Hospice Care Givers and Support Staff are about....

                                  Compassionate Caring

                                   Creating Connections

                                     Causing Change

                                  Commitment to Quality

                              Principles and Values
                     Patients and other customers are our first priority

                            Quality is achieved through people

                                All work is part of a process

                             Decisions are made based on facts

                              TABLE OF CONTENTS

                             Mission and Vision Statement
                                 Emergency Numbers

SECTION A: Admission Information

Chapter 1   All About Hospice
            Questions and Answers                                   2-3
            Hospice Services                                        3-4
            The Role of the Hospice Staff                           5-6
            Volunteer Services                                      6-7
            Bereavement Services                                    7-8
Staff Assignments
            Mutual Goals Statement                                   9

Chapter 2   You Give Consent                                      10-11
            Your Rights and Responsibilities                      11-13
            Notice of Privacy Practices                              14
            Use and Disclosure With Consent                       15-16
            Use and Disclosure Without Consent                    17-19
            Authorization to Use or Disclose Health Information      19
            Your Rights With Respect to Your Health Information   20-21
            Duties of the Hospice                                 21-22

Chapter 3   Caring For You                                        23-24
            Advance Directive Documentation                       24-25

Chapter 4   Contracted Services                                   26-30
            Durable Medical Equipment (DME)                       31-32
            Inpatient Care                                        32-33
            Outpatient Care                                          33
            Respite Care                                             33
Hospice in the Nursing Home

            Ambulance Services                                      34
            In Summary, What Does Mercy Hospice Provide?            35
Chapter 5   Financial Information                                 36-40

Chapter 6   Emergency Preparedness                                41-50
                               TABLE OF CONTENTS

SECTION B: Teaching Information

Chapter 7    Primary Care Giver Guidelines                 51-54

Chapter 8    Signs and Symptoms of Approaching Death       55-60

Chapter 9    Infection Control and Universal Precautions   61-66
             Disposal of medications- Mercy Care policy
Chapter 10 Lifting and Moving Patients                     67-73

Chapter 11 Environment and Mobility Safety                 74-76

Chapter 12 Fire Safety                                     77-81

Summary of Information                                        82
                                  EMERGENCY NUMBERS

Animal Shelters
Grand Strand Human Society               448-9151
 North Myrtle Beach                      249-4948
 Horry County Animal Shelter             347-3898

Lymo-Waccamaw Regional                   488-0865
Transportation Authority (Public Bus)    TDD 488-0872

DHEC Hot Line                            1-800-922-6735

DHEC Shelter Information                 365-7684
CHAP (Community Health Accreditation     1-800-656-9656

Emergency Help Line (911)                248-1520

Emergency Preparedness
 Conway                                  248-1225
 Horry County Emergency Management       626-1225

Horry County Council on Aging            1-800-868-9095

Horry County Police (Conway)             248-1790

Horry County Sheriff                     915-5450

 Conway Medical Center                   347-7111
 Grand Strand Regional Medical Center    692-1000
 Loris Community Hospital                716-7000
 Georgetown Memorial Hospital            527-7000

Long-Term Care, Ombudsman Division       1-803-898-2850
(Columbia, SC)

Mercy Hospice & Palliative Care          347-5500
(24-hours a day/7 days a week)

State Highway Patrol (Conway)            365-5001
           Quality Requires Continuous Improvement
                                     Chapter 1

                               All About Hospice

What is Hospice?
Hospice is a special way of caring for terminally ill people and their families. A
terminal illness can be devastating and have far-reaching effects. Patients and their
families need a solid support system during this time of crisis. Mercy Hospice is
ready to provide that support. Our mission is to not only relieve physical symptoms
such as pain but also the emotional and spiritual pain that often accompanies a
terminal illness.

A patient’s environment can be crucial in maintaining comfort and peace of mind
during a terminal illness. Mercy Hospice allows the patient to die at home, in
familiar surroundings, with dignity and privacy. We do realize that this is not always
possible; therefore, we also care for patients who are hospitalized and living in
nursing facilities. Our focus in not on death itself. Our primary purpose is to help
patients live with their illness while maintaining the highest possible quality of life.

We provide an extensive support system of experienced, compassionate
professionals. The Hospice team is made up of physicians, nurses, social workers,
home health aides, chaplains, counselors, and trained volunteers. Our goal is to
work closely with the patient’s physician and family to offer comfort and ensure that
the symptoms of the patient’s illness are controlled.

Mercy Hospice is a non-profit organization. Patients are admitted and have access
to services without discrimination due to race, color, national origin, age, sex,
religion, handicapping condition, ability or inability to pay for services, and
regardless of the patient’s primary language. Our Hospice complies fully with Title
IV of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and
the Age Discrimination Act of 1975.

We are committed to providing the highest quality hospice home care to you as
well as ensuring your rights as a patient. This booklet has been prepared to assist
you in learning about our services and procedures. If you have any additional
questions, please do not hesitate to ask us.

                            Questions and Answers

When should a decision about hospice care be made?
When faced with a terminal illness, the patient and family should discuss all options
for care–symptom control or aggressive treatment to the disease. This discussion
could occur with their physician, the hospice referral liaison, other healthcare
providers, or clergy. If the decision is made to make the patient comfortable
through control of symptoms and not treat aggressively, then Hospice is

Are patients ever discharged from hospice?
Yes. If the patient’s condition improves and they no longer meet hospice criteria,
the patient will be discharged from hospice. The discharged patient can re-enter the
program at a later time if needed. Patients may also stop hospice services if they
wish to seek aggressive treatment.

How is hospice paid for?
Medicare, Medicaid, Tri-Care, and most private insurance companies cover hospice

Does hospice do anything to make death come sooner?
No. Hospice does nothing to hasten the end of life. Our goal is comfort and
support. Hospice allows death to occur naturally while being there to provide
support and knowledge during the dying process.

Does someone need to be with the patient all the time?
If the patient is able to get up and care for their activities of daily living, it will not
be necessary to have someone with them all the time. However, if the patient is
bedridden, hospice recommends that someone stay with the patient all the time.

What if I can no longer manage my loved one at home?
Your Hospice team is there to support you. You must let us know your concerns
and if you feel you are unable to manage at home; your Hospice team will work
with you on long-term placement.

Can the patient return to the hospital?
Patients may be hospitalized if necessary for symptom control, caregiver crisis, or
impending death, with the approval of their physician and Hospice.

Can I still go see my doctor?
Yes. Please let your Hospice nurse know if you have any doctor appointments.

Do I have to have a “Do Not Resuscitate” (DNR) order to be on hospice?
No, you do not have to have a DNR order. You always have the right to choose the
type of care you wish to receive. Discuss your desires and DNR status with your
physician. Information concerning advance directives and DNR can be found in
Chapter 3 of this guide. By choosing Hospice, you are choosing a non-aggressive
form of care. Therefore, Hospice does not pay for services involved in resuscitation,
for example, 911 calls or non-approved hospitalization.

                                  Hospice Services
The Admission Process
Mercy Hospice serves residents in the following communities:

Myrtle Beach, Socastee, North Myrtle Beach, Little River, Longs, Loris, Aynor,
Conway, Gallivants Ferry, Nichols, Surfside Beach, Garden City, Murrells Inlet,
Bucksport, and unincorporated communities located in Horry, Georgetown, and
Marion counties.

Family, friends, physicians, or other healthcare agencies can make referrals. All
referrals will be evaluated for appropriateness of admission to Hospice. Diagnoses
include but are not limited to:
       ●   Alzheimer’s disease                               ●   Stroke
       ●   Dementia                                          ●   End-stage AIDS
       ●   ALS                                               ●   Failure to Thrive
       ●   End-stage lung, cardiac or renal disease          ●   Cancer

Admission to Hospice is based upon your needs and the recommendation of your
physician. Patients appropriate for Hospice care should meet the following criteria:

   •   Have a terminal illness.

   •   Be seeking care that is based on comfort rather than cure.

   •   Have a responsible care giver or agree to develop an alternative plan of care
       consistent with the patient’s safety and needs.

On admission, a member of our staff will visit you and your family to discuss
Hospice services, assess your needs, and initiate your plan of care.
Hours of Operation
Mercy Hospice is located on Singleton Ridge Road, behind Coastal Federal Bank, in
the Waccamaw Medical Park Mall. Our office hours are Monday through Friday,
8:00 a.m. to 6:00 p.m. Coverage is available 24 hours a day, 7 days a week
through an emergency on-call service when our office is closed, on weekends, and
on holidays. A qualified Hospice nurse is available to accept patient calls, referrals,
and to arrange for patient services as needed. Call 347-5500 and follow the
promptings given on the automated telephone call system.

Plan of Care
Upon admission, the Hospice interdisciplinary team will develop an individual plan of
care for you. It is based on your admission information, physical assessment, your
physician’s specific medication and treatment orders, and your personal wishes.

The plan includes four basic areas:

   •   Physical care

   •   Personal care and comfort

   •   Spiritual needs

   •   Psychosocial needs and bereavement care

The plan is reviewed and updated based on your changing needs. Medical
information will be provided to assist you in participating in your plan of care.

Discharge and Transfer
A discharge or transfer from Hospice may occur in the following situations:

   •   The level of care in which your need changes.

   •   You move out of our service area.

   •   You decide to seek aggressive, curative care.

   •   You no longer desire Hospice care.

You will be given advance notice of transfer to another agency or of discharge. If
you are transferred to another agency, we will provide the necessary information
for your continued care. In case of discharge, an assessment will be done and
instructions provided for ongoing care.
                        The Role of the Hospice Staff

The Medical Director
The Hospice Medical Director attends the interdisciplinary team meeting, gives
guidance to the staff regarding the patient’s plan of care, and is available to the
patient’s attending physician for consultation.

Primary Care Nurse
Upon admission, you will be assigned a primary care nurse who will coordinate and
manage your care. Nurses have extensive training and clinical proficiency. They
treat all patients with compassion and understanding. Services provided by our
nursing staff include:

   •   Regularly scheduled visits.

   •   On-call services 24-hours a day, 7 days a week.

   •   Coordination of care.

   •   Pain and symptom management.

   •   Skilled assessments.

   •   Training of family in patient’s care.

Social Worker
A social worker is available to help the patient and their families deal with the
emotional issues and challenges that may be faced during a terminal illness.
Services include:

   •   Provide emotional support and guidance to the patient and family.

   •   Identify community resources, which may be available to help you.

   •   Assist with financial concerns if appropriate.

   •   Assist with Living Wills and/or Durable Power of Attorney for Health Care.

Certified Nursing Assistants (CNAs)
Certified Nursing Assistants are available to assist the family with care such as
bathing, dressing, grooming, hair care, nail care, skin care, shaving, ambulating
assistance, and linen changes. Days of service vary depending upon the patient’s

Hospice spiritual care is based upon a high respect for the patients and caregivers
personal faith and beliefs. Our chaplains do not impose their belief system or seek
to change the belief system of others. Instead, they are available to offer spiritual
support to patients and their families as they face the challenges of a terminal

                             Volunteer Services

Volunteers: Who Are They?
A Hospice volunteer is simply a friend you haven’t met yet! Volunteers are like
neighbors you may have or wish you did have. They are emotionally mature,
caring, sensitive, and loving people!

Volunteers believe that you can have the best quality of life possible, regardless of
how long that time may be. They focus on your needs and the needs of your
family. They approach the end-of-life in an open and direct way and are willing to
help you and your family to do the same.

Volunteers are committed, dedicated women and men from all walks of life. They
are thoroughly trained and understand their role as Hospice volunteers. They
communicate with the Hospice staff so that they can support you and your family
during a fragile time in your lives.

What Do They Do ?
Hospice volunteers are good listeners. They can talk openly about issues of dying
that may be very sensitive and difficult for you to discuss with your family
members. Volunteers know how important it is to respect your rights, including
confidentiality. Volunteers are good company, whether you want someone just to
sit in silence, watching TV together, reading a book or newspaper to you, or talking
about anything you feel you are up to discussing. Volunteers may do some chores
around the home, providing their health and capability allows. They may run
errands, pick up medical supplies, or do some grocery shopping. They are also
available to make trips to hospitals and doctors’ offices. Volunteers do not provide
direct patient care. They may help prepare a single meal but will not assist in
feeding you.

How Do They Relate To Me?
Volunteers can be an invaluable friend for you and your family. They help relieve
the pressure that your illness places on you and your family. They are not baby
They are caring and loving people, many of whom have walked in your shoes in
their own lives.

For more information about how to obtain a volunteer, call the Mercy Hospice
Volunteer Director at (843) 347-5500 and request to speak to the Volunteer

                            Bereavement Services

Mercy Hospice is committed to the health and well being of adults and children
anticipating or affected by the death of a loved one. Because people experience
and work through grief in different ways, Mercy Hospice offers a variety of services
for one year following the death of a loved one.

Support Groups
Mercy Hospice offers several kinds of support groups. These groups are open to the
community as well as to families of Mercy Hospice patients.

Healing Grief Support Group is held several times a year, meeting once a week for
six weeks. It offers help in understanding the grief process and learning new coping
skills. Participants commit to the group, they do not move in and out of the group
at will.

One-to-One Support through short-term, individual, and pastoral counseling is
available and can be scheduled by appointment.

Grief Support Groups are uniquely designed for children and adults experiencing
grief due to the death of a loved one.

A Correspondence Program provides written material with suggestions for coping
with grief during the first difficult year.

Presentations are available to community groups to provide information on Hospice
services as well as grief and loss education for children, adolescents, and adults.

The Tree of Celebration Memorial Event is held each year in December to
remember deceased loved ones. Friends and relatives can remember a loved one
by adding a light to the Mercy Hospice Tree of Celebration. Lights on the Tree are
donated in memory or in honor of a loved one. The tree is displayed in a prominent
location in the Conway area.
Children’s Services
Children’s Bereavement Services help children, pre- adolescents, and adolescents
to understand, express, and deal constructively with loss and change. These
services include:

   •   Consultation, education, and grief support within family, school, and
       community settings.

   •   Crisis intervention, assessment, and referral.

Camp Happy Hearts is a one-day bereavement camp for children, offered several
times throughout the year. Children who have lost a significant person in their lives
within the last year or who are having problems dealing with their grief are
encouraged to attend. Camp Happy Hearts is staffed by trained professionals and

                               Staff Assignments

Your primary nurse will visit once or twice a week for approximately 30 to 45
minutes each visit. On occasions, you may meet other nursing staff during on-call
hours or when your assigned nurse is not available due to emergency, vacation, or
educational involvements.

The Social Worker working with you will contact you within two working days of
admission to the program. She will visit to explain her services and assess your
needs. The schedule of visits is set according to need, most commonly twice a

Your Certified Nursing Assistant (CNA) will be assigned if these services are needed.
CNAs provide personal care and work under the direction of the nurse. The
frequency of their visits is determined by the care required. The maximum number
of visits per week is determined based on the patient needs identified by the
patient/family and hospice team in your plan of care. You may meet other
members of the CNA staff when it is necessary to evenly distribute the workload or
cover for those staff members who are absent due to vacations, illness, or
educational involvements.

Within five days of admission, the CNA will visit at least once. After that, the
hospice aide will provide services based on the plan of care developed by the
patient/family and hospice interdisciplinary team. Before visiting each assigned day,
the aide will phone to let you know the approximate time of her visit. This allows
you to pre-medicate to control pain and allow ease of care. At the beginning of the
week, she can give you a generalized idea of the days she will be coming during
that week. Please keep in mind that the schedule is subject to change. Nursing
assistants stay approximately 60 minutes and assist with personal care including
bathing, hair shampoos, shaving, dressing, positioning in bed, transfer from bed,
and change of bed linens (upon request). They will also teach you how to deliver
this care in their absence.

Mercy Hospice employs a full-time Chaplain. The Chaplain will call to set up an
appointment to visit within five days of admission to the program and determine
your needs in the area of spiritual care.

The Volunteer Coordinator will be in contact with you by phone within five days of
admission to offer this service and determine your needs for a volunteer(s).

Mercy Hospice staff can be reached by calling the office at 347-5500. Normal office
hours are 8:00 a.m. to 6:00 p.m., Monday through Friday.

                          Mutual Goals Statement
I, as the patient / care giver (please circle one) agree that the following are the
goals that I and my loved ones want to achieve while receiving Hospice services. I
and my care givers agree to participate in following the instructions because they
will promote my comfort. I and my care givers will help with these goals by taking
the medications as directed and letting the agency know when there has been a
change or a problem.

I agree to participate with Mercy Hospice staff in:

   •   Managing pain that allows the patient to be comfortable.

   •   Managing bladder and bowel patterns, including constipation.

   •   Managing nutrition and hydration to the point of comfort.

   •   Promoting healthy skin condition.

   •   Promoting adequate sleep and rest.

   •   Minimizing and managing previous conditions to promote comfort.

   •   Providing information and support regarding funeral preparation.
   •   Promoting safety.

   •   Providing spiritual support and comfort based on patient and family desires.
   •   Providing a comforting death with dignity.
                                    Chapter 2

                               You Give Consent

Informed Consent
I hereby consent to admission to and care by Mercy Hospice. I understand that
hospice is designed to relieve symptoms such as pain, other physical discomfort,
and the emotional stresses which may accompany my terminal illness. I understand
that the care I elect in hospice is palliative and not curative. Accordingly, I hereby
direct my attending physician and Mercy Hospice not to order or administer any
treatment which would only prolong the process of dying and is not necessary for
my comfort or to alleviate pain.

I understand that if I am to receive the full benefits of hospice care it is important
for me to make needs and concerns known to the hospice staff. I will actively
participate in plans for my care. I recognize that hospice services are not intended
to take the place of care by family members or others, but rather to support them.
I understand that care will be provided by scheduled appointments, but a nurse is
available for phone consultation and assistance 24 hours a day, 7 days a week at

I understand that:
   •   Medical treatment for relief of pain and symptoms is appropriate for my
       terminal illness.

   •   Services are primarily provided in the home by a team.

   •   My medical care remains under the direction of my personal physician.

   •   Services may be terminated by written request, at any time by myself.

   •   Discharge may occur if I no longer meet the admission criteria.

   •   When Mercy Hospice provides reimbursement for services, those services will
       be rendered by a contracted provider. If I use a non-contracted provider,
       payment for those services will be my responsibility.

   •   The hospice staff will treat me, my family and my property with respect.

   •   I understand that I have the right to voice grievances regarding treatment
       or care, or regarding lack of respect for me, my family, my property, without
       being subjected to discrimination or reprisal for doing so.

   •   I may contact the Director of Nursing at 347-5500, Monday through Friday
       from 8:00 a.m. to 4:30 p.m., who will register my complaint and respond
       within two working days.

   •   I may also call the State Hotline (1-800-922-6735, 24 hours a day, 7 days a
       week) to register a complaint.

Basic services to be provided may include:
   •   Services by a nurse and social worker. Optional: home health aide,
       volunteers, and chaplain.

   •   Medical supplies, medication and equipment to manage my terminal illness
       at home, if covered by my insurance plan.

   •   Short-term care in a hospital or skilled nursing facility which has a contract
       with Mercy Hospice if covered by my insurance plan.

Basic services DO NOT include:
   •   Any services which have not been pre-approved by Mercy Hospice and
       included in my Plan of Care.

   •   Any services which are curative in nature and/or seek to prolong life

   •   Financial responsibility for life-saving equipment.

                     Your Rights and Responsibilities

All patient to whom our services are being provided have basic rights. You have the
right to:

   •   Be fully informed of your rights and receive this notice before the beginning
       of care.

   •   Be treated with dignity, consideration and respect by professional staff.

   •   Exercise your rights or your family or guardian may exercise your rights if
       you have been judged incompetent.

   •   Have your person and property treated with respect and privacy.

   •   Know in advance if you will be responsible for any costs.

   •   Be informed by a physician of your medical condition and be given an
       opportunity to participate in designing the care plan for your needs and
       updating it as your condition changes.

   •   Be advised in advance of the discipline of staff who will provide care and the
       proposed frequency of visits.

   •   Expect confidentiality of all information related to your care within

   •   Have your pain appropriately assessed and managed.

   •   Refuse treatment and be told the consequences of your actions.

   •   Be informed within a reasonable time of anticipated termination of services.

   •   Have your family taught about your illness so that you can help yourself and
       your family can understand and help you.

   •   Formulate an Advance Directive.

   •   Voice grievances regarding care or lack of respect for property without being
       subject to discrimination or reprisal.

   •   Talk with an agency Supervisor or Manager about any aspect of your care by
       calling the Director of Nursing at 347-5500.

   •   Call the State Hotline (1-800-922-6735, 24 hours a day, 7 days a week) to
       file a complaint, ask questions regarding Hospice providers, and make known
       your concerns.

   •   Call the Community Health Accreditation Program (CHAP) at 1-800-656-9656
       from 8AM to 6PM, Monday through Friday, to have questions answered
       about the organization or to voice a complaint.

Patient Responsibilities
All patients receiving our services have certain responsibilities. It is your
responsibility to:
    • Remain under a doctor's care while receiving agency services and report any
      unexpected changes in your condition to the physician.

   •   Provide the agency with a complete and accurate health history.

   •   Provide the agency all requested insurance and financial reports.
   •   Sign the required consents and releases for insurance billing.

   •   Participate in your plan of care and express any concern about your
       understanding of the course of treatment or your ability to comply with

   •   Notify the agency about changes in plan of care, i.e., moving out of
       state/area, initiation of nursing home care, hospitalization, diagnostic testing,
       and treatment changes.

   •   Secure pets when Hospice staff members are in the home to give care.

   •   Accept the consequences for any refusal of treatment or choice of
   •   Provide a safe home environment in which your care can be given and follow
       instructions for performing procedures and using equipment.

   •   Cooperate with your doctor, agency staff and other caregivers.

   •   Treat agency personnel with respect and consideration and notify the agency
       if you will not be home for a previously scheduled visit.

   •   Advise the agency of any problems or dissatisfaction with our care, without
       being subject to discrimination or reprisal.

   •   Inform the professional or the agency regarding your Advance Directive and
       supply a copy to the agency for inclusion in your record.

   •   Notify the agency when rental equipment is no longer needed.

   •   Respond to the agency’s surveys regarding your satisfaction with the hospice

This agency is an affirmative action/equal opportunity employer and does not
discriminate on the basis of race, color, national origin, sexual orientation, religion,
sex, disability, or age.

                         Notice of Privacy Practices
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
You will be treated with consideration and respect. We recognize your right to
dignity and privacy in treatment and in the care of your personal needs. At times,
an additional individual may be present during a visit for reasons of safety,
education, or supervision.         This may include Medicare surveyors, media
representatives, student interns, etc. Prior to visiting your home, we will ask your
permission and have you sign a consent form. You have the right to refuse this
request, and this refusal will not compromise your care in any way.

Use and Disclosure of Health Information
Mercy Hospice may use your health information for purposes of providing you
treatment, obtaining payment for your care and conducting health care operations.
Your health information may be used or disclosed only after the Hospice has
obtained your written consent.

The Hospice has established a policy to guard against unnecessary disclosure of
your health information.

                    Use and Disclosure With Consent

The following is a summary of the circumstances under which and purposes for
which your health information may be used and disclosed after you have provided
written consent:

To Provide Treatment
The Hospice may use your health information to coordinate care within the Hospice
and with others involved in your care, such as your attending physician, members
of the Hospice interdisciplinary team and other health care professionals who have
agreed to assist the Hospice in coordinating care. For example, physicians involved
in your care will need information about your symptoms in order to prescribe
appropriate medications.

The Hospice also may disclose your health care information to individuals outside of
the Hospice involved in your care including family members, clergy whom you have
designated, pharmacists, suppliers of medical equipment or other health care
professionals that the Hospice uses in order to coordinate your care.

To Obtain Payment
The Hospice may include your health information in invoices to collect payment
from third parties for the care you may receive from the Hospice. For example, the
Hospice may be required by your health insurer to provide information regarding
your health care status so that the insurer will reimburse you or the Hospice. The
Hospice also may need to obtain prior approval from your insurer and may need to
explain to the insurer your need for hospice care and the services that will be
provided to you.

To Conduct Health Care Operations
The Hospice may use and disclose health care information for its own operations in
order to facilitate the function of the Hospice and as necessary to provide quality
care to all of the Hospice's patients. Health care operations includes such activities

   •   Quality assessment and improvement activities.

   •   Activities designed to improve health or reduce health care costs.

   •   Protocol development, case management and care coordination.

   •   Contacting health care providers and patients with information about
       treatment alternatives and other related functions that do not include

   •   Professional review and performance evaluation.

   •   Training programs including those in which students, trainees or practitioners
       in health care learn under supervision.

   •   Training of non-health care professionals.

   •   Accreditation, certification, licensing or credentialing activities.

   •   Review and auditing, including compliance reviews, medical reviews, legal
       services and compliance programs.

   •   Business planning and development including cost management and
       planning related analyses and formulary development.

   •   Business management and general administrative activities of the Hospice.

   •   Bereavement program activities.

   •   For example the Hospice may use your health information to evaluate its
       staff performance, combine your health information with other Hospice
       patients in evaluating how to more effectively serve all Hospice patients,
       disclose your health information to Hospice staff and contracted personnel
       for training purposes, use your health information to contact you as a
       reminder regarding a visit to you, or contact you or your family as part of
       general fund raising and community information mailings (unless you tell us
       you do not want to be contacted).
For Fundraising Activities
The Hospice may use information about you including your name, address, phone
number and the dates you received care at the Hospice in order to contact you or
your family to raise money for the Hospice. The Hospice may also release this
information to a related Hospice Foundation. If you do not want the Hospice to
contact you or your family, notify the Administrator at (843) 347-5500 and indicate
that you do not wish to be contacted.

                  Use and Disclosure Without Consent

Federal privacy rules allow the Hospice to use or disclose your health information
without your consent or authorization for a number of reasons:

When Legally Required
The Hospice will disclose your health information when it is required to do so by
any Federal, State or local law.

When There Are Risks to Public Health
The Hospice may disclose your health information for public activities and purposes
in order to:

   •   Prevent or control disease, injury or disability, report disease, injury, vital
       events such as birth or death and the conduct of public health surveillance,
       investigations and interventions.

   •   To report adverse events, product defects, to track products or enable
       product recalls, repairs and replacements and to conduct post-marketing
       surveillance and compliance with requirements of the Food and Drug

   •   To notify a person who has been exposed to a communicable disease or who
       may be at risk of contracting or spreading a disease.

   •   To an employer about an individual who is a member of the workforce as
       legally required.

To Report Suspected Abuse, Neglect or Domestic Violence
The Hospice is required to notify government authorities if the Hospice believes a
patient is the victim of suspected abuse, neglect or domestic violence. The Hospice

will make this disclosure only when specifically required or authorized by law or
when the patient agrees to the disclosure.

To Conduct Health Oversight Activities
The Hospice may disclose your health information to a health oversight agency for
activities including audits, civil administrative or criminal investigations, inspections,
licensure or disciplinary action. The Hospice, however, may not disclose your health
information if you are the subject of an investigation and your health information is
not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings
The Hospice may disclose your health information in the course of any judicial or
administrative proceeding in response to an order of a court or administrative
tribunal as expressly authorized by such order or in response to a subpoena,
discovery request or other lawful process, but only when the Hospice makes
reasonable efforts to either notify you about the request or to obtain an order
protecting your health information.

For Law Enforcement Purposes
The Hospice may disclose your health information to a law enforcement official for
law enforcement purposes as follows:

   •   As required by law for reporting of certain types of wounds or other physical
       injuries pursuant to the court order, warrant, subpoena or summons or
       similar process.

   •   For the purpose of identifying or locating a suspect, fugitive, material witness
       or missing person.

   •   Under certain limited circumstances, when you are the victim of a crime.

   •   If the Hospice has a suspicion that your death was the result of criminal
       conduct including criminal conduct at the Hospice.

   •   In an emergency in order to report a crime.

   •   In an emergency to seek help for you in a life-threatening situation.

To Coroners and Medical Examiners
The Hospice may disclose your health information to coroners and medical
examiners for purposes of determining your cause of death or for other duties, as
authorized by law.

To Funeral Directors
The Hospice may disclose your health information to funeral directors consistent
with applicable law and if necessary, to carry out their duties with respect to your
funeral arrangements. If necessary to carry out their duties, the Hospice may
disclose your health information prior to and in reasonable anticipation of your

For Organ, Eye or Tissue Donation
The Hospice may use or disclose your health information to organ procurement
organizations or other entities engaged in the procurement, banking or
of organs, eyes or tissue for the purpose of facilitating the donation and

For Research Purposes
The Hospice may, under very select circumstances, use your health information for
research. Before the Hospice discloses any of your health information for such
research purposes, the project will be subject to an extensive approval process. The
Hospice will
ask your permission before any researcher will be granted access to your
individually identifiable health information.

In the Event of A Serious Threat To Health Or Safety
The Hospice may, consistent with applicable law and ethical standards of conduct,
disclose your health information if the Hospice, in good faith, believes that such
disclosure is necessary to prevent or lessen a serious and imminent threat to your
health or safety or to the health and safety of the public.

For Worker's Compensation
The Hospice may release your health information for worker's compensation or
similar programs.

For Specified Government Functions
In certain circumstances, the Federal regulations authorize the Hospice to use or
disclose your health information to facilitate specified government functions relating
to military and veterans, national security and intelligence activities, protective
services for the President and others, medical suitability determinations and
inmates and law enforcement custody.

       Authorization to Use or Disclose Health Information

Other than is stated above, the Hospice will not disclose your health information
other than with your written authorization. If you or your representative authorizes
the Hospice to use or disclose your health information, you may revoke that
authorization in writing at any time.
      Your Rights With Respect to Your Health Information
You have the following rights regarding your health information that the Hospice

Right to request restrictions
You may request in writing restrictions on certain uses and disclosures of your
health information. You have the right to request a limit on the Hospice's disclosure
of your health information to someone who is involved in your care or the payment
of your care. However, the Hospice is not required to agree to your request. If you
wish to make a request for restrictions, please contact the Administrator at (843)
347-5500 or P.O. Box 50640, Myrtle Beach, SC 29579.

Right to receive confidential communications
You have the right to request that the Hospice communicate with you in a certain
way. For example, you may ask that the Hospice only conduct communications
pertaining to your health information with you privately with no other family
members present. If you wish to receive confidential communications, please
contact the Administrator at (843) 347-5500 or P.O. Box 50640, Myrtle Beach,
South Carolina, 29579.

The Hospice will not request that you provide any reasons for your request and will
attempt to honor your reasonable requests for confidential communications.

Right to inspect and copy your health information
You have the right to inspect and copy your health information, including billing
records. A request to inspect and copy records containing your health information
may be made to the Administrator. If you request a copy of your health
information, the Hospice may charge a reasonable fee for copying and assembling
costs associated with your request.

Right to amend health care information
If you or your representative believes that your health information records are
incorrect or incomplete, you may request that the Hospice amend the records. That
request may be made as long as the information is maintained by the Hospice. A
request for an amendment of records must be made in writing to the Administrator.
The Hospice may deny the request if it is not in writing or does not include a reason
for the amendment. The request also may be denied if your health information
records were not created by the Hospice, if the records you are requesting are not
part of the Hospice's records, if the health information you wish to amend is not
part of the health information you or your representative are permitted to inspect
and copy, or if, in the opinion of the Hospice, the records containing your health
information are accurate and complete.
Right to an Accounting
You or your representative have the right to request an accounting of disclosures of
your health information made by the Hospice for any reason other than for
treatment, payment or health operations. The request for an accounting must be
made in writing to the Administrator. The request should specify the time period for
the accounting starting on April 14, 2003. Accounting requests may not be made for
periods of time in excess of six years.

The Hospice would provide the first accounting you request during any 12-month
period without charge. Subsequent accounting requests may be subject to a
reasonable cost-based fee.

Right to a paper copy of this notice
You or your representative have a right to a separate paper copy of this Notice at
any time even if you or your representative have received this Notice previously. To
obtain a separate paper copy, please contact the Administrator.

                            Duties of the Hospice
The Hospice is required by law to maintain the privacy of your health information
and to provide to you and your representative this Notice of its duties and privacy
practices. The Hospice is required to abide by terms of this Notice as may be
amended from time to time. The Hospice reserves the right to change the terms of
its Notice and to make the new Notice provisions effective for all health information
that it maintains. If the Hospice changes its Notice, the Hospice will provide a copy
of the revised Notice to you or your appointed representative. You or your personal
representative have the right to express complaints to the Hospice and to the
Secretary of Health and Human Services if you or your representative believe that
your privacy rights have been violated. Any complaints to the Hospice should be
made in writing to the Administrator. The Hospice encourages you to express any
concerns you may have regarding the privacy of your information. You will not be
retaliated against in any way for filing a complaint.

Patient/Family Satisfaction
The quality of care and your satisfaction with the care you receive is very important
to us. A survey will be mailed to the family three months after the agency has
finished its service to you and your family. Please take a moment to complete it
and return it to us in the self-addressed envelope that will be enclosed. Your
comments and recommendations help us to improve our services.
If there are concerns or complaints about services received by Mercy Hospice,
please call (843) 347-5500 and ask to speak with the Nursing Care Coordinator.
He/she will take information from you, investigate the complaint, and phone you
back with a resolution within two working days. If these concerns/complaints are
not resolved, you may call state DHEC (Department of Health and Environmental
Control) Hot Line at 1-800-922-6735. Both numbers are available 24 hours a day, 7
days a week.

The Hospice's contact person for all issues regarding patient privacy and your rights
under the Federal privacy standards is the Administrator: (843) 347-5500 or P. O.
Box 50640, Myrtle Beach, South Carolina, 29579.

                                    Chapter 3

                                Caring For You

Nursing Care: Routine and Emergency Situations
Nursing care is one of the services you will receive as a hospice patient/family. Your
nurse will visit on a regular basis to assess the patient's condition. She will be
working with your doctor to manage pain and other symptoms of illness. The nurse
will teach you how to care for the patient in your own home. And we will include
the other hospice team members in your care to enhance your quality of life during
this time.

When the nurse visits, please communicate any concerns you may have. Report on
the following to the nurse during each visit:

   •   Appetite

   •   Bowel function

   •   Medication schedule and effectiveness

   •   Equipment needs

   •   Prescription needs

   •   Any new or changing symptoms

In addition to the regular scheduled visits by the nurse, you are encouraged to call
the office if you need additional consultation with the nurse assigned to your care.

Hospice provides on-call availability of a nurse 24 hours a day, seven days a week.
You may reach the on-call nurse by calling the Hospice office number 347-5500.
When the office is closed, an answering service will take your name and phone
number and have the on-call nurse return your call. If the nurse does not return
your call within 15 minutes, call again.

         Please do not call 911 before calling the on-call nurse.
                 We will handle the situation as needed.

The following are considered after-hours emergency situations:

   •    Uncontrolled pain

   •    Falls or injuries

   •    Difficulty breathing

   •    Prolonged nausea, vomiting, or diarrhea

   •    Seizures

   •    Hemorrhaging

   •    Agitation or restlessness

   •    Unresponsiveness

   •    Signs of impending death

   •    A temperature above 101 that does not respond to Tylenol

          If these or other alarming symptoms occur, call the nurse for
       assistance. If unable to reach the on-call nurse, call your physician.

                      Advance Directive Documentation
You have the right to make all decisions about the health care you receive. If you
do not want certain treatments, you have the right to tell your doctor, either orally
or in writing, that you do not want them. Most patients can express their wishes to
their doctor, but some that are badly injured or unconscious cannot. People need to
know your wishes in case you become unable to make decisions yourself. The best
way to be sure your wishes are followed is to sign an Advance Directive.

Our Hospice complies with the Patient Self-Determination Act of 1990 which
requires us to:

   •   Provide you with written information describing your rights to make decisions
       about your medical care.

   •   Document Advance Directives, place a copy in your medical records, and
       inform all staff.

   •   Comply with requirements of state law and court decisions with respect to
       Advance Directives.

   •   Provide care to you regardless of whether or not you have executed an
       Advance Directive.

An Advance Directive is a legal document that gives specific directions for your
medical care if you are unable to do so. It protects your rights. There are two types
of advance directives: a Living Will and a Health Care Power of Attorney.

A Living Will is a document stating that you want to be allowed to die a natural
death and not be kept alive by medical treatment, heroic measures, or artificial
means that will not improve your health. It only goes into effect when you are no
longer able to make decisions for yourself.

A Health Care Power of Attorney is a document in which you give another
person the power to make decisions related to your health care. You should appoint
a person you trust and who knows how you feel about health care. Both of these
documents can be changed or canceled while you are still competent and able to do
so. We must document in your medical records whether or not you have an
Advance Directive. We also need a copy for our records.

It is our policy to honor your Advance Directive and to support your rights as a
patient to participate in health care decisions. Please inform us if you execute or
change any of these documents during the course of your care.

On June 12, 1991, South Carolina adopted a new Living Will form. The old form
does not say anything about permanent unconsciousness and does not allow tube
feedings to be withheld in most situations. If you signed a Living Will in South
Carolina prior to June 12, 1991, it is still valid. However, you may want to review
your Living Will and consider signing a new one.

A Do Not Resuscitate (DNR) is a specific order from your physician not to start
cardiopulmonary resuscitation (CPR). This means no attempts would be made to try
and restart your heart after it has stopped beating. Your wishes regarding this will
be discussed at the time of your referral to Hospice. This is a separate order from
an Advance Directive and also needs to be documented in your medical records.
You may change your wishes regarding your DNR status at any time.

Mercy Hospice uses two (2) forms of DNR orders. One is signed by your physician
expressing your wishes while you are in your home. The second DNR order applies
to the event in which you may be in an ambulance for transfer to a hospital,
emergency room, or physician office. If you agree to a DNR, please display the
notice prominently in your home and be certain that everyone knows of your desire
not to be resuscitated.

Please ask your Hospice team if you have any questions about the above, need
more information, or wish to complete an Advance Directive. You may also call:

Horry County Council on Aging                                      1-800-868-9095
Long-term Care, Ombudsman Division, Columbia, SC                   1-803-898-2850

                                   Chapter 4

                            Contracted Services

For those who have the Medicare Part A/Medicaid/ Tri-Care Hospice Benefit, Mercy
Hospice pays for medications ordered by your physician, directly related to your
terminal illness, and approved by your nurse. This includes narcotics for pain and
medications which relieve symptoms caused by your terminal illness. In order for
drugs to be paid for they MUST be obtained from a pharmacy which has a contract
with Mercy Hospice because these pharmacies work closely with Hospice in caring
for persons with special medication needs.

Upon admission to Mercy Hospice, you will:

   •   Designate which pharmacy on the Mercy Hospice list you will use.
       (Note: Responsive Solutions is the only pharmacy which may deliver
       drugs to your home. Family members will have to pick up drugs from other
       contracted pharmacies.)

   •   Be given a drug card to be shown to the pharmacist in order for Mercy
       Hospice to pay for these particular drugs.

Mercy Hospice will:

   •   Send a list of drugs ordered for you to the pharmacy so that when you pick
       up the drugs, the pharmacist knows they are paid for by Mercy Hospice.

   •   Notify the pharmacy of any new, approved medication orders received from
       your physician. If a nurse approves, the new medication is added to the list
       at the pharmacy and billed to Mercy Hospice.

Mercy Hospice does not cover non-prescription (over-the-counter) medications.
Private Insurance
For those who have insurance coverage, patients will continue to use their current
pharmacy and/or prescription plan. The patient is responsible for all co-payments
and deductibles.

For those who no not have insurance coverage, arrangements must be made by the
patient to pay the pharmacy privately. Our experienced Medical Social Workers

may be able to assist you in applying for financial assistance through other local
agencies. Please let your Medical Social Worker know if you need assistance with
prescription costs.

Medication Tips
   •   Be sure your doctor(s), nurse(s), and pharmacist(s) are aware of any drug or
       food allergies that you may have had in the past.

   •   Be sure all your doctor(s), nurse(s), and pharmacist(s) are aware of all
       medications you are using. This includes medications taken by mouth,
       injections, suppositories, drops, creams, ointments, and patches.

   •   Store your medications as directed. If they look different (for example, an
       odd color or odor) contact your nurse before you take the medications.

   •   Know what medicines the patient should take, why the patient is taking
       them, and when they should be taken. Take as directed.

   •   Always check prescription labels for correct name, dose, and frequency.

   •   Keep only current prescriptions. Do not use expired drugs. Discard any
       outdated medications. Ask the nurse for guidance, if needed.

   •   Establish a reliable medication dispensing system or designate someone to
       assist with medication setup. For example, use trays or a pillbox to organize
       different medicines and to indicate when they should be taken.

   •   Keep a daily log. Record the time, amount, type and dosage of each
       medicine taken.

   •   Report side effects or new symptoms to the nurse.

   •   Do not add or change medications without approval of the doctor.

   •   Always call the nurse if you have any questions.

   •   Keep all medications out of the reach of children at all times.
   •   Secure all caps on medication bottles.

   •   Store syringes behind a closed door and do not talk about the fact that you
       have syringes in your home.

   •   Never expose medication–in or out of bottles–to sunlight. (This precaution
       applies to injectable medications, such as insulin.)

   •   If a medicine upsets your stomach, talk to your physician, nurse, or
       pharmacist before adding any over-the-counter medicine, herbal remedies,
       or diet/vitamin supplements.

Constipation: A Common Problem
What is constipation?
Constipation is defined as infrequent, irregular, or incomplete bowel movements.
Pain and straining from the passage of hard, dry stools are often experienced as

While it may be a sign of serious disease, constipation is more likely due to minimal
amounts of fluid intake, too little fiber in the diet, lack of exercise, the normal
process of aging, or the result of taking certain prescription and over-the-counter

What medications are likely to cause constipation?
Medications prescribed for arthritis, high blood pressure, high cholesterol,
depression or anxiety, pain, or various heart-related conditions may cause
constipation and require the use of a laxative to obtain relief from the effects.

             It is not at all unusual for opioid and non-opioid pain
                        medications to cause constipation.

What can help prevent constipation?
The following activities can help provide relief from constipation and promote
normal bowel function:

   •   Eat foods rich in fiber and drink plenty of fluids.
   •   Relax regularly and enjoy your meals in a leisurely manner.
   •   Engage in some moderate, routine exercise to help tone up your whole body
       as well as your sluggish bowel.

   •   Establish a regular routine for going to the bathroom.
   •   Ask your doctor, nurse, or pharmacist when taking any prescription drug if
       constipation is likely and if there are any other side effects you may
   •   Seek assistance in dealing with constipation. At Mercy Hospice, we
       encourage the use of Senokot, a natural vegetable laxative. It is a gentle,
       predictable, effective laxative that works overnight.
   •   Keep taking your medications unless ordered to stop by your physician. Do
       not quit taking the medications simply because you believe it may be causing
       constipation and discomfort. Check with your physician and follow their

Laxative Protocol
A daily bowel regimen should be followed just as carefully as your doctor’s other
instructions. The overall goal is to have a bowel movement approximately every 2-4
day(s). Because responses vary, use the guidelines below to find a regimen that
works best for you. If at any time the dosage of your pain-relieving medication is
changed, you may also need to increase or decrease your daily dosage of laxative.
Speak with your Hospice Nurse for a change in dose.

   1. Take two Senokot-S tablets at bedtime.
      If you do not have a bowel movement in the morning,

   2. Take two Senokot-S tablets after breakfast.
      If you do not have a bowel movement by evening,

   3. Take three Senokot-S tablets at bedtime.
      If you do not have a bowel movement in the morning,

   4. Take three Senokot-S tablets after breakfast.
      If there is no bowel movement within 48 hours after starting the protocol.

   5. Continue to take three Senokot-S tablets in the morning and three Senokot-
      S tablets in the evening and consult your nurse for additional instructions.

Once you start having bowel movements, use the two steps prior to your last one
as your daily laxative protocol. For example, if you achieved a bowel movement
after Step 4, use Steps 2 and 3 (that is, two Senokot-S tablets in the morning
and three Senokot-S tablets at bedtime) as your daily regimen.

Remember, constipation is a common side effect of many medications. A daily
bowel regimen helps to prevent this potentially troublesome side effect.

If you are unsure about what to do, please call your nurse at 347-5500 for advice.

                   Durable Medical Equipment (DME)

Some medical equipment is covered by the Hospice Medicare/Medicaid/Tri-Care
Benefit. Mercy Hospice contracts with several medical equipment (DME) companies
throughout Horry County to supply such needs. Equipment needs are based on the
nursing assessment.

Sometimes, a patient may have equipment in the home that is provided by a
company that does not contract with Mercy Hospice. In these instances, such
equipment will be returned to the provider and a contracted company will place the
required equipment in the home.
If at any time, there is a change in the patient’s needs for care, please contact the
Mercy Hospice office and equipment needs will be arranged.

When the patient no longer requires the equipment, the Mercy Hospice staff will
contact the DME company. The company will then contact the family on the next
weekday to arrange for pick-up of the equipment.

Pick-ups are not conducted on weekends or holidays. Only emergency
oxygen delivery is conducted at those times.

Mercy Hospice will arrange for necessary medical equipment needed to keep the
patient at home. The following is a list of DME that is covered:

   •   Semi-electric hospital bed.
   •   Standard wheelchair.
   •   Nebulizer (only with a COPD diagnosis upon admission).
   •   Oxygen and oxygen supplies.

   •   Suction equipment and supplies.

The following will be considered with demonstrated medical necessity:

   •   Over-bed trapeze.
   •   Geomat (over the mattress alternating pressure pad).
   •   Over-bed table (for COPD diagnosis only).
   •   IV infusion supplies.
   •   Hoyer lifts based on RN assessment and caregiver capability.

The following are not covered:

   •   Specialty mattress.
   •   Bed-side commode.
   •   Shower chair.
   •   Electric wheelchair.
   •   Lift chair.
   •   Shower bars.

Mercy Hospice is contracted with the following DME company:

Allcare Medical Equipment                1-888-299-0004

                                Inpatient Care

For those who elect the Medicare Part A, Medicaid, or Tri-Care Hospice benefit,
inpatient services may be provided when the physician, the Hospice Medical
Director, and Hospice team assess the need for round-the-clock care for intensive
symptom control. The goal of inpatient services is to help the patient and family
become physically and emotionally stable enough to return home, when possible.

For those with private insurance, the hospital will bill the insurance company
directly. The patient is responsible for all deductibles and co-pays. For those
without insurance, financial arrangements must be made by the patient or caregiver
directly with the facility.
Hospice does not provide for long-term hospitalization, custodial, or nursing home
care. Inpatient care may be provided only in a hospital under contract with Mercy

   Costs associated with an inpatient stay at non-contracting hospitals will
   be the responsibility of the patient/family and is not covered by Hospice.

                               Outpatient Care
Outpatient and emergency services are available at contracting facilities when
arranged by Hospice. Financial responsibilities noted above apply. The following is a
list of facilities to be used for inpatient or outpatient care, for patients on the
Medicare/Medicaid/Tri-Care Hospice Benefit:

             Name                        Location                   Phone
Conway Medical Center                    Conway                     347-7111
Georgetown Hospital                      Georgetown                 527-7000
Grand Strand Regional Medical Center     Myrtle Beach               692-1000
Loris Healthcare System                  Loris                      716-7000
Marion Regional Healthcare System        Marion                     431-2000
Waccamaw Community Hospital              Murrells Inlet             652-1000

                                  Respite Care

Respite care is a short-term inpatient stay which may be necessary in order to give
temporary relief to those helping with a terminally ill patient’s care. Respite care
may be provided at the following contracting facilities for up to five (5) days at a
time for those who are on the Medicare Part A/Medicaid/Tri-Care Hospice Benefit:

             Name                        Location                   Phone
Conway Manor                             Conway                     248-5728
Kingston Nursing Center                  Conway                     347-8179

Loris Extended Care Facility             Loris                      716-2106

                       Hospice in the Nursing Home
Hospice is available for the terminally ill nursing home patients. Mercy Hospice has
contracts with the following long-term care facilities:
             Name                        Location                   Phone
Conway Manor                             Conway                     248-5728
Grand Strand Healthcare                  Myrtle Beach               293-1137
Kingston Nursing Center                  Conway                     347-8179
Loris Extended Care                      Loris                      716-7106
Myrtle Beach Manor                       Myrtle Beach               449-5283
National Healthcare                      Murrells Inlet             650-2213

                               Ambulance Services

For those on the Medicare Part A/Medicaid/Tri-Care Hospice Benefit, TranMed, LLC
is the Mercy Hospice contracted and approved service that covers Myrtle Beach,
Socastee, North Myrtle Beach, Little River, Longs, Loris, Aynor, Conway, Galivants
Ferry, Nichols, Surfside Beach, Garden City, and Murrell’s Inlet.

All dispatches are handled by calling their corporate office located in Georgetown at
545-7911. Your primary nurse will arrange for transportation if it is deemed

  Mercy Hospice is not responsible for charges incurred for unauthorized
services or when the service is unrelated to the Hospice admitting diagnosis.

For those with private insurance, the ambulance service will bill the insurance
company directly. The patient is responsible for all deductibles and co-pays. For
those without insurance, financial arrangements must be made by the patient or

caregiver directly with the company.

          In Summary, What Does Mercy Hospice Provide?

Mercy Hospice will provide or make arrangements for all:

   •   Skilled nursing services.
   •   Medical social services.
   •   Certified Nursing Assistants.
   •   Medical supplies/equipment.
   •   Symptom control medications.
   •   Outpatient services, including laboratory testing.
   •   Transportation to the hospital, if needed.
All inpatient, respite, and outpatient care must be arranged by the Hospice nurse
and the attending physician.

 If services are not pre-approved by Mercy Hospice, the patient/family may
                  be responsible for the bill for the services.

                                   Chapter 5

                           Financial Information
Mercy Hospice admits patients to the Hospice program based on need and
regardless of their ability to pay. Medicare, Medicaid, and most private insurance
companies cover hospice services.

Veterans Administration benefits pay only for RN visits. Services prescribed by a VA
physician require authorization by the VA Fee Basis Unit in order for payments to be
made. We will make every effort to obtain this authorization.

Charitable donations allow us to provide Hospice services to patients without a
payment source.

Coverage of Hospice services varies among insurance companies and policies range
from 0 percent to 100 percent coverage. We will contact your insurance carrier and
notify you regarding what services your policy covers and what percentage they will
reimburse us after you have met your deductibles.

Upon admission, you and your caregiver will be informed of any charges for
services and method of payment. We will bill your insurance company and in most
cases they will pay Hospice directly. You will be advised should any change be
made regarding your services or charges.

Short-Term Inpatient Care
Mercy Hospice provides short-term inpatient care for patients when the patient
cannot be cared for within the home setting. Inpatient care is only utilized as a
backup for home care when the patient's physical symptoms are not able to be
managed in the home.

          You must call the Hospice Nurse for approval before you
        go to a hospital. The Nurse will speak with your physician and
                 make the admission procedure easier for you.

Mercy Hospice has contracts with the following hospitals and you must be
hospitalized in one of the following hospitals if you are a participant in the Hospice
Medicare or Medicaid Benefit Program:

                  Conway Medical Center, Conway, SC
                   Loris Healthcare System, Loris, SC
     Grand Strand Regional Hospital Medical Center, Myrtle Beach, SC
             Marion Regional Healthcare System, Marion, SC
                  Georgetown Hospital, Georgetown, SC
           Waccamaw Community Hospital, Murrells Inlet, SC

The following are the Medicare rates Hospice receives for persons eligible for the
Medicare Benefit. These rates change annually.

                  Visit Type                           Reimbursement
             Routine Home Care                         $130.96 per day

             Inpatient Respite Care                    $137.45 per day

             General Hospital Inpatient Care           $585.31 per day

Private Insurance
The agency accepts private insurance payment. Each insurance program is different
and agency professionals will assist you to inquire about hospice and benefits with
your insurance carrier.

Private Funds
The costs of care may be offset by personal contributions. A flexible billing process
is available based on need.

Medicare Benefits
The Hospice program is palliative, not curative, in its goals and techniques for
helping patients with life-limiting illness.

As a Medicare beneficiary, the patient would elect to receive care under the
Medicare Program entitled Hospice Care. The Medicare Benefit consists of three (3)
certification periods; two (2) 90-day periods and one (1) 60-day period, renewable
each 60 days. Hospice care for each period must be approved by the Hospice
Medical Director.

Hospice pays for physician services, treatments, and services related to the life-
limiting illness. It is the patient’s responsibility to (1) seek pre-approval to
determine whether the service is covered, and (2) which provider to use.

If the patient prefers to obtain service from a service provider not under contract
with Mercy Hospice, or does not seek pre-approval for a service, the patient will be
responsible for all costs associated with the service provided.

Medical Care
Services provided to the patient at home by the Hospice Interdisciplinary Team
(nurse, social worker, nursing assistant, volunteer(s), and chaplain), will be in
accordance with the patient’s Plan of Care and may include the following:

   •   Intermittent visits by the team members providing nursing, counseling,
       social, pastoral, and personal care services.

   •   Intermittent visits and/or consultation by auxiliary team members providing
       dietary, physical, occupational, and speech therapy.

   •   Management of related physical symptoms.

   •   Instruction for the patient and caregivers in managing care.

   •   Counseling and emotional support for the patient’s family/caregivers.

   •   Hospice-trained volunteers to augment the professional services.

   •   Durable medical equipment and supplies approved for my Hospice care.

   •   Continuous home care services for short periods during a medical crisis.

   •   Twenty-four hour per day on-call service by registered nurses to answer
       questions and respond in times of crisis.

  •   Prescriptions and biologicals as needed for pain and symptom control
      provided by pharmacies under contract with Mercy Hospice. If the patient
      prefers to obtain this service from a different pharmacy, the patient would be
      responsible for all costs associated with those prescriptions and Mercy
      Hospice would not be financially responsible for any part of those costs.
      Generic drugs will be dispensed. Pre-authorization is required otherwise with
      valid explanation for the use of brand name drugs.

  •   Bereavement services are available for primary caregivers for a period of one

Inpatient Care
  •   The Hospice program is primarily a home care service and is not available to
      provide long-term hospitalization, custodial, or nursing home care.

  •   The patient may receive pre-authorized inpatient services when their
      physician, the Hospice Medical Director, and the Interdisciplinary Team
      believe that the patient needs round-the-clock inpatient care and intensive
      symptom control. The goal of inpatient services it to help the patient and
      the family become emotionally and physically stable enough for the patient
      to go home, if at all possible.

  •   Inpatient care may also be authorized for short-term respite care or relief for
      the patient’s caregivers.

  •   Inpatient care that is covered by the Medicare Hospice Benefit may be
      provided only in a hospital under contract with Mercy Hospice. If the patient
      prefers hospitalization in a different facility, the patient would be responsible
      for all costs associated with that period of inpatient care and Mercy Hospice
      would not be financially responsible for any part of that inpatient care.

Other Medicare Benefits
  •   During the period that the patient receives Hospice care, the patient agrees
      to waive rights to services offered under the traditional Medicare Benefit for
      their life-limiting illness, since they will be receiving services under the
      Medicare Hospice Benefit.

  •   If the patient has physical problems unrelated to their Hospice diagnosis, the
      patient may choose to receive medical care for those problems either under
      the traditional Medicare program or through some other reimbursement


   •   The patient may revoke their election of Hospice care at any time during an
       election period and thereby resume the Medicare coverage of the benefits
       waived. To revoke the election, the patient must file a Revocation Statement
       with Mercy Hospice. At a later date, the patient may elect to receive Hospice
       coverage again for any of the remaining election periods that the patient is
       eligible to receive.

   •   The patient may elect to change Hospice programs only once in each of the
       certification periods.

Continuation of Care
Hospice services to the patient will continue as long as the Interdisciplinary Team
considers the services appropriate, necessary, and as long as the condition

Revocation of the Medicare Benefit
Only a beneficiary or their representative may revoke the election of the Hospice
Medicare Benefit. A beneficiary or his/her representative may revoke the HMB at
any time for any reason after which the regular Medicare Part A benefits will be
reinstated. The beneficiary may not designate an effective date earlier than the
actual date the revocation is made and signed. If a beneficiary chooses to revoke
the HMB, he/she (or the beneficiary’s representative) must sign a statement
providing the beneficiary is aware of the revocation and indicating why the
beneficiary chose to revoke. A verbal revocation is not acceptable.

When a patient is non-compliant, the hospice may counsel the beneficiary on their
option to revoke and any advantages or disadvantages of the decisions they make.
A patient would be non-compliant if:

   •   He/She seeks aggressive treatment for the terminal illness; or

   •   He/She seeks treatment in a facility that does not have a contract with the
   •   He/She seeks treatments that are not in the hospice plan of care or are
       pre-approved by the hospice.

                                     Chapter 6

                          Emergency Preparedness
In the event of a natural disaster such as a flood, tornado, hurricane or ice storm,
the following instructions are ways to take care of yourself and your family. The
staff will make all attempts to contact you before, during, and after the natural
disaster to assure your safety and assist you with problems that arise during such
an occurrence. You need to be aware that the agency obeys all directives given by
the local Emergency Management Office and is observant of the curfews imposed
during and after the occurrence of a natural disaster. In the event that the
telephone communications are disrupted and curfews are imposed, you will need to
be prepared to depend upon yourself, family members, or neighbors to assist you
to meet your care giving responsibilities.

Floods can develop over a period of days, but flash floods can occur in just a few
minutes. Be aware of flood hazards, especially if you live in a low-lying area or near

If a flood watch is issued:

   •   Gather emergency supplies.

   •   Be prepared to evacuate.

   •   Secure your home.

   •   Turn off utilities at the main switches if instructed to do so.

   •   Do not walk through moving water.

   •   Use a stick to check the firmness of the ground in front of you.

A tornado is nature’s most violent storm. They move rapidly. In case of a tornado
watch or warning:

   •   Stay away from windows, doors, and outside walls.

   •   Go to an interior room of your home that does not have windows, always on
       the lowest level.

   •   If a patient is bed bound, move the bed away from the window and cover
       with heavy blankets.

   •   If you are in a car or in a mobile home, get out and go to a nearby building.
       If one is not available, lit flat in the nearest ditch. Cover your head with your

Winter Storms
Extreme cold, occasional snowfall, and icy conditions can cause blocked roadways,
accidents, and downed power lines. In case of a winter storm:

   •   Gather emergency supplies.

   •   Dress in several layers of warm clothing rather than one layer.

   •   Always wear a hat–most body heat is lost through the top of your head.

Hurricane Preparation
Think and Plan Ahead
Do you have a plan? What is it? Will you go to a hospital? Neighbors? Family
member? Shelter? Out of town? How will you get there?

Going to a shelter should be your last resort during a disaster which requires
evacuation. Individuals and families should seek shelter with relatives, friends, or
hotels outside the area. Shelters only provide the very BASICS of shelter, food, and
first aid.

Pets, weapons, alcohol, and drugs are not allowed in a shelter. Please make
provisions for your pets with your veterinarian or local animal shelter. It is also
helpful to let family members, outside of the local area, know that you are going to
a shelter–if you decide to go to one.

The Department of Health and Environmental Control operates two types of

   •   Red Cross Shelters for the general public.

   •   Special Medical Needs Shelters.

Before You Go To A Red Cross Shelter
DHEC/Red Cross Shelters are usually held in a high school gym and provide food
and a nurse for first aid only. Those coming to the shelter bring their own supplies,
blankets, chairs, radios, etc.

   •    Do you or the patient use medical equipment? Is the patient on a
        ventilator/respirator, breathing treatment machine, apnea monitor, IV pump
        or suction equipment (In the event of a power failure, the patient
        would not be safe in a shelter.)

       The patient cannot go to a shelter using plug-in medical equipment.
                Batteries fail and electricity may not be available!
        Recommendation: Leave town or go to a hospital. The patient’s doctor can
        help with the arrangements. Call Mercy Hospice first to assist if you plan to
        leave town or go to a hospital.

   •    Is the patient violent, uncontrollable, prone to loud/angry outbursts?
        If so, the patient cannot go to a shelter. It would be a safety risk for
        others in the shelter. Contact Mercy Hospice to have your physician arrange
        for hospitalization or to leave town.

Special Medical Needs Shelters
A Special Medical Needs Shelter is a temporary facility which can provide
“special/nursing care” during an emergency situation. If a caregiver is needed, the
caregiver from the home or a private-duty nurse must accompany and stay with the
person at the shelter.

Who Should Go?
Individuals whose age, frailty, mobility, functional and/or medical disability make
them particularly vulnerable and at-risk in disaster situations are good candidates.
Someone whose physical or mental condition exceeds the capabilities of the Red
Cross shelters but not severe enough to require hospitalization are also welcome.

For example:

   •    Wheelchair bound persons with medical needs (catheters, dressings, etc.).

   •    People receiving IV medication.

•   People needing frequent wound dressing changes.

•   Oxygen dependent persons. Must have portable tanks that can last up to 72

•   Individuals with severely reduced mobility (bed bound, partial paralysis).

•   Patients newly discharged from a hospital and needing skilled observation.

•   Comatose patients. The patient would be more comfortable in a

•   If in a shelter, the patient must have a battery back up suction machine.

•   Medically impaired individuals who are able to maintain activities of daily
    living with special assistance, such as:

•   Intermittent or continuous infusion (pain control or hydration). Must have IV
    pump with battery backup pack that will last 72 hours or can drip safely.

•   Various ostomies (colostomies, tracheotomies-must have battery back up
    suction machine).
•   Internal feedings (bolus or continuous drip).
•   Foley or supra pubic catheters.

                           What Are Your Medical Problems?

                              You may be able to go to You may not go to a
       Diagnoses              a Special Needs Shelter Special needs Shelter
                              if...                    if...
    Cardiovascular              If no chest pain in the     If you have chest pain
  Myocardial Infarction              past 2 weeks.          now or if you have had
     (heart attack)                                          chest pain in the past
         Angina                                                   two weeks.
Congestive Heart Failure
      Respiratory                 Oxygen dependent            High concentrations:
         Asthma                  1-3 liters per minute          3 liters or higher
      Emphysema                                                      Requires
          COPD                 Suctioning not required.      ventilators/respirators
  Ventilator Dependent                                         Requires breathing
     Tracheotomies                                            machine treatments
                                                               (IPPB, Nebulizers)
                                                             Cannot tolerate heat.
                                                              Suctioning required.
   Urological/Renal               When is your next        Patient to call the Dialysis
         Dialysis                  appointment for          Center. Cannot perform
     Foley Catheter                  treatment?                  at the shelter.
  Supra pubic Catheter
        Urostomy                Bring supplies, diapers,
   Incontinent bladder               linen savers.
      and/or bowel

                       What Are Your Medical Problems?

       Diagnoses           You may be able to go to     You may not go to a
                           a Special Needs Shelter      Special needs Shelter
                           if...                        if...
        Diabetes           Bring medications and
                           blood sugar (glucose
                           monitor machine) and
      Neurological                                      If requires suctioning,
CVA-stroke                 Bring equipment and          make another plan (no
Head injury                supplies.                    electricity).
Moderate to severe
mental retardation                                      You have had no seizures
Limited mobility                                        in last 24 hours.
Epilepsy/seizures                                       Recommend comatose
Comatose                                                person to be moved to
                                                        hospital/taken out of
         Wounds            Bring supplies.
Post-Op Surgery
Stasis Ulcers
      Tube feeding
      Gastrostomy          Bolous/Gravity Feedings.     Requires pump.
         IV Fluids         Bring supplies and orders.   Requires pump.
Intermittent IV Infusion

                             Bring medications and
  Infectious Diseases        notify staff on entering

               *If the patient is dependent upon electrical power,
                        then hospitalization is required.*

This shelter is designed as a last resort facility. Individuals with medical
impairments who have been able to maintain activities of daily living in a home
environment prior to the disaster or emergency situation should make
arrangements to seek other shelter if at all possible (such as a friend, family, or in a
hotel outside the threatened area.)

For further information or help in deciding if a Special Medical Needs
Shelter is right for you, please call (843) 365-7684 or 1-888-422-3646

Think and Plan Ahead
   •   The greater the threat, the more critical it is to move non-ambulatory
       patients and to execute your plan.

   •   Listen for weather updates; follow instructions.

   •   Call the Local Emergency Management Office for the nearest shelter and
       evacuation route.

   •   Try to leave before nightfall.

   •   Arrange for pets’ safety.

   •   Stay away from windows and glass doors.

   •   Tell someone where you are going.

   •   Shut off electricity, gas, and water.

   •   If you live in a mobile home, LEAVE !

   •   If an evacuation notice is issued, review this checklist, take your carry-out
       bag or luggage and LEAVE !

Public Transportation--Lymo Waccamaw Regional Transportation Authority
Lymo Waccamaw Regional Transportation Authority is the public transportation
provider for Horry and Georgetown Counties which offers an Emergency Evacuation
Program so residents can easily evacuate the Grand Strand area during a hurricane

Evacuation Pickup Points
There are seven (7) designated hurricane evacuation pickup points:

   1. Inlet Square Mall.

   2. The old Myrtle Beach Air Force Base Main Gate.

   3. Pavilion parking garage.

   4. Myrtle Square Mall.

   5. Food Lion at 79th Avenue North.

   6. Colonial Mall.

   7. North Myrtle Beach Lowe’s store.

Look for the pickup point closest to your home. If you are unsure which is closest,
please call customer service at 488-0865. Tell them where you are and where you
want to go.

All evacuation rides start and end at officially designated emergency shelters.

Evacuation Tips If Using Public Transportation:

   •   Find a seat quickly so the bus can continue its trip.

   •   Leave the front seats vacant for elderly and disabled customers who may
        board after you.

   •   Take few belongings with you. Do not bring excess belongings or pets on
       the bus. Only seeing eye dogs or trained personal assistant animals are

When Evacuating To A Shelter, Bring The Following Items:
   •   Medical Support Equipment
       Wheelchair, walker, oxygen, feeding equipment, ostomy, etc.
   •   Medical Supplies
       A 3-day supply of diapers, underpads, catheters, and any wound care

   •   Medications
       A 3-day supply of all medications you are taking and any written instructions.
       The name, phone number of physician, and Mercy Hospice’s phone number.

•   Bottled Water or Drinks
    Enough for each person, for several days.

•   Special Dietary Needs
    A 3-day supply of special food items (example: a diabetic diet). Only regular
    meals will be provided. Brings snacks and a can opener in a plastic bag.

•   Sleeping Gear
    Pillows, blankets, portable cot or air mattress, folding chairs.

•   Hygiene Items
    Toothbrush, toothettes, deodorant, diapers/linen savers, cleansing wipes
    (such as baby wipes), soap, toilet and facial tissue.

•   Baby and Small Child Care
    Diapers, formula, clean bottles, wipes, snacks, pacifiers, clothing, bedding,
    portable playpen, small toys for amusement.

•   Personal Items
    Clothing, small games, books, cards, wind-up clock.

•   Important Papers
    Insurance papers, written doctor’s instructions, DNR papers.

•   Identification
    With photo and current address.

•   Cash
    Check cashing/credit card services may not be available for several days
    after the storm. Don’t bring too much! There will be no place to secure
    money or valuables at the shelter.
•   Extra clothing
    An extra set of comfortable clothing and a few extra sets of underwear and

•   Flashlights and batteries, battery-operated radio.

•   Be sure to fill the gas tank in the car!

If The Patient and Caregiver Are Staying Home
Be sure to have the following additional supplies at hand:

   •   First aid kit.
   •   Canned and non-perishable foods.
   •   Manual can opener.
   •   Rope.
   •   Waterproof covering.
   •   Canvas tarpaulin.
   •   Eating utensils (paper plates, cups, plastic forks, etc.)
   •   Pet food (enough to last for several days).
   •   Baby supplies (enough to last for several days).
   •   Plastic bags.
   •   Car tire sealant.
   •   Gas camp cook stove (with filled reserve tank).

                                   Chapter 7

                      Primary Care Giver Guidelines
Caring for a loved one with a terminal illness and undergoing many physical,
emotional, mental, and spiritual changes can be a challenging and fulfilling
experience, as well as confusing and tiring. Mercy Hospice supports your willingness
to undertake the role of Primary Care Giver for your loved one. By doing so, you are
allowing them to remain in comfortable and familiar surroundings during life’s final
journey. We will journey with you and teach you what you need to know.

Our Hospice staff realizes that this period of time is one of the most difficult times
for the family to live through, sometimes because “fear of the unknown” is greater
than the fear of the known. Our desire is to be as honest and straightforward as
possible in helping you through this period. We are here to provide information to
help you prepare for and understand symptoms which may be seen toward the end
of life. By working as a team, each one having different roles and responsibilities,
we can provide the most benefit to you and your loved one.

As the primary caregiver, you may be asked to do such things as maintain the
patient’s hygiene, nourishment, and give medications. It may involve such comfort
measures as preventing constipation and nausea, turning, skin care, oral care,
bathing, and grooming. You may be asked to learn such skills as ostomy care and
how to use special equipment. Generally, it means being available to your loved
one to listen, to touch, to share, to be present, and to care.

Your individual Hospice team will support you in every possible way, helping with
your limitations and frustrations; helping you to arrange for supportive services
needed in the home; and dealing with your own feelings regarding this situation
and how it is affecting your life. We will help you clarify available options and
implement them in the most helpful manner.

We will explain the progression of the illness, how the needs of your loved one will
change, and how to respond as these changes take place. We want to describe
possible symptoms in order to decrease your fear if one should appear suddenly
and give you some guidelines about what you can do about the symptoms. The
symptoms described are indicative of how the body prepares itself for the final
stage of life. Not all of these symptoms will appear at the same time and some
may never appear.

When you think death has occurred, please call the Hospice office. We will send a
Hospice nurse to your home who will handle calls to the coroner and your doctor.
You will not need to call the police, paramedics, EMS, or the fire department.

Please know that although this information may sound frightening, our goal is to
prepare you for what to expect. Your physical and emotional well being are as
important to us as the dying person’s. The value of the gift of care giving will make
the patient’s remaining time on earth full of meaning, dignity, and respect. In doing
all you can do to facilitate your loved one’s comfort and peace, you are also giving
yourself a great gift.

Skin Care
It is important to try and keep the patient’s skin in good condition. Due to their
disease, Hospice patients may have weakness, loss of weight, and low nutritional
intake–all of which can cause skin problems. Bedsores or decubitus ulcers may
occur in those who are confined to bed and don’t or can’t change their position. The
most likely areas to develop bedsores are the sacrum (the tailbone area), elbows,
heels, and hips.

When the patient remains in a chair or bed for an extended period of time, it is
important to take precautions. Some helpful steps to follow are listed below:

   •   Check the patient’s skin each day for reddened areas or breakdown.

   •   Turn every 2-3 hours to relieve the pressure. With a bed-bound patient, a
       sheet can be used to assist with turning or lifting. The Hospice Certified
       Nursing Assistant (CNA) or nurse will teach you how to do this.

   •   Use lots of pillows to both support and comfort the patient.

   •   Give pain medications as scheduled to make sure that movement is as pain-
       free as possible.

   •   Keep the patient’s skin clean and dry.

   •   Keep bed linens dry and wrinkle free.

   •   Gently massage reddened areas. Apply lotion to skin once or twice each day
       to prevent dryness.

   •   Egg crate mattresses and heel/elbow protectors may be helpful.

In spite of all efforts, a bedsore may still develop. If this occurs, the Hospice nurse
will help determine the best way to treat the bedsore.

Tips on Mouth Care
Mouth care is also important for Hospice patients. Regular mouth care may prevent
sores and may improve the patient’s desire to eat.

   •   Allow patient to perform own oral care if able.

   •   Perform mouth care at least two times a day.

   •   Do not perform mouth care with the patient lying flat.

   •   Use a moisturizer, such as Vaseline, on lips to prevent drying. Apply as
       needed throughout the day. Do not use Vaseline if patient is on oxygen.

   •   If a mouth sore(s) develop, notify Hospice.

Difficult Breathing
Sometimes difficult breathing, known as shortness of breath, can occur in Hospice
patients. You may notice feelings of anxiety, restlessness, as well as faster
breathing. Things you can do to help include:

   •   Be calm and reassuring. Stay with the patient.

   •   Raise the head of the bed.

   •   Fans and cool-air humidifiers may be helpful.

   •   Give medication for pain or anxiety as ordered.

           Please call your Hospice nurse about difficult breathing.
                       Your physician may order oxygen.

Anxiety, Confusion, Restlessness
Changes in behavior such as anxiety, confusion, and restlessness will be
experienced during the disease process. These changes are normal and to be
expected but hard for both. The following are things you can do to help:

   •   Respect the patient’s mood.

   •   Maintain a consistent environment with familiar objects.

   •   Keep the room quiet. You may need to limit visitors.

   •   Have a calendar and clock available to maintain orientation.

   •   Use a night light.

   •   Sit with the patient and maintain physical contact, like a light touch and hand

   •   Provide verbal reassurance.

   •   Read to the patient.

   •   Play soft music.

Things to Remember
Constipation is a common but uncomfortable problem in Hospice patients;

   •   Keep a record of bowel movements.

   •   Notify Hospice if there is no bowel movement in 3 days.

   •   Increase fluid intake without overloading the patient.

   •   Give laxatives as ordered.

                                    Chapter 8

             Signs and Symptoms of Approaching Death

What To Do To Add Comfort
You have chosen to keep your dying loved one at home in familiar surroundings.
This is the greatest gift of love you have to offer your loved one. We of Mercy
Hospice support your desire and want to be open and honest with you about what
to expect and how to respond.

Death occurs when the body completes its natural process of shutting down and
when the “spirit” completes its natural process of reconciling and finishing. These
two processes need to happen in a way appropriate to the values, beliefs, and life-
styles of the dying person. This is not the time to change your loved one but the
time to give full acceptance, support, and comfort.

The following signs and symptoms of impending death may be observed as your
loved one approaches the final stages of life. We give you this information to help
you prepare for, anticipate, and understand symptoms that you may observe. Not
all these symptoms will appear at the same time and some may never appear.
Knowing what might happen will lessen your stress at this very difficult time.

The following signs and symptoms described are indicative of how the body
prepares itself for the final stage of life, which is death.

   •   Coolness
       The person’s hands, arms, feet, and then legs may be increasingly cool to
       the touch. At the same time, the color of the skin may change. The
       underside of the body may become darker (bluish) and the skin becomes
       mottled. This is a normal indication that the circulation of blood is decreasing
       to the body’s hands, arms, legs, and feet and that it is being reserved for the
       most vital organs. Keep the person warm with a blanket, but do not use an
       electric blanket.

   •   Sleeping
       The person may spend an increasing amount of time sleeping and appear to
       be uncommunicative or unresponsive. At times, he/she may be difficult to
       arouse. This normal change is due in part to changes in the metabolism of
       the body. Sit with your loved one, hold his/her hand. Do not shake him/her
       or speak loudly but speak softly and naturally. Plan to spend time with

    him/her during those times when he/she seems most alert and awake. Do
    not talk about the person in

    their presence. Speak to him/her directly as you normally would, even
    though there may be no response. Never assume the person cannot hear.
    Hearing is the last of the senses to be lost.

•   Confusion of Mind (Disorientation)
    Confusion about time, place, and the identity of people surrounding him/her
    including close and familiar people may occur in part to the metabolic
    changes. Identify yourself by name before you speak rather than ask the
    person to guess who you are. Speak softly, clearly, and truthfully when you
    need to communicate something important for the patient’s comfort such as
    “it is time to take your medications”, and explain the reason for the
    communication such as, “so you won’t begin to hurt”. Do not use this
    method to try to manipulate the patient to meet your needs.

•   Loss of Bladder and Bowel Control (Incontinence)
    Loss of control of urinary/bowel functions may happen as the muscles in that
    area begin to relax. Discuss with your Hospice nurse what can be done to
    protect and keep your loved one clean and comfortable.

•   Congestion in Lungs or Throat
    The person may have gurgling sounds coming from his/her chest as though
    marbles were rolling around inside. These sounds may become very loud.
    This normal change is due to the decrease of fluid intake and inability to
    cough up normal secretion. Gently turn the person’s head to the side and
    allow gravity to drain the secretions. You may also gently wipe the mouth
    with a moist cloth. The sound of congestion does not indicate the onset of
    severe new pain or pneumonia.

•   Restlessness
    Restlessness may be observed and repetitive motions such as pulling bed
    linens or clothing. This often happens and is due in part to the decrease in
    oxygen circulation to the brain and to changes in metabolism. Do not
    interfere with or try to restrain such motions. To have a calming effect,
    speak in a quiet, natural way. Lightly massage the forehead, read to the
    person, or play some soothing music.

•   Fluid and Food Decrease
    The person may have a decrease in appetite and thirst, wanting little or no
    food or fluid. This is the body’s natural way to begin to conserve energy. Do
    not try to force food or drink or try to use guilt to persuade the person into
       eating or drinking something. Doing so only makes the person much more

       Small chips of ice, frozen Gatorade, or juice may be refreshing in the mouth.
       If the person is able to swallow, fluids may be given in small amounts by
       syringe (ask the Hospice nurse for guidance). Toothettes may help
       keep the mouth and lips moist and comfortable. A cool, moist washcloth on
       the forehead may also increase physical comfort.

   •   Urine Decrease
       Urine output normally decreases and may become “tea” colored–often
       referred to as concentrated urine. This is due to the decreased fluid intake as
       well as decrease in circulation through the kidneys. Consult with your
       Hospice nurse to determine whether there may be a need to insert or irrigate
       a catheter (a tube into the bladder).

   •   Breathing Pattern Change
       Regular breathing patterns often change. The person may move into
       “cheynestokes” breathing (shallow breathing with periods of no breathing for 5 to
       30 seconds and up to a full minute). The person might also experience periods
       of rapid, shallow, pant-like breathing. These patterns are very common and
       indicate a decrease in circulation in the internal organs. Elevating the head
       and/or turning the person on his/her side may bring comfort. Hold his/her
       hand. Speak gently.

   •   Temperature Elevation
       The person’s regular temperature may become elevated. This is common
       and comfort measures should be taken. Consult with your Hospice nurse to
       determine what is the best treatment. A cool, moist washcloth on the
       forehead may help to provide comfort.

Normal Emotional-Spiritual Mental Signs and
Symptoms with Appropriate Responses
Unusual Communication
The person may make a seemingly “out of character” statement, gesture, or
request. This indicates that he/she is ready to say “good-bye” and is “testing” to
see if you are ready to let him or her go. Accept the moment as a beautiful gift
when it is offered. Kiss, hug, hold, cry, and say whatever you most need to say.

•   Withdrawal
    The person may seem unresponsive, withdrawn, or in a comatose-like state.
    This indicates preparation for release, a detaching from surroundings and
    relationships, and a beginning of “letting go.” Since hearing remains all the

    to the end, speak to your loved one in your normal tone of voice. Identify
    yourself by name when you speak, hold his/her hand and say whatever you
    need to say that will help the person “let go.”

•   Vision-Like Experiences
    The person may speak or claim to have spoken to persons who have already
    died or see or have seen places not presently accessible or visible to you.
    This does not indicate a hallucination or a drug reaction. The person is
    beginning to detach from this life and is being prepared for the transition so
    it will not be frightening. Do not contradict, explain away, belittle, or argue
    about what the person claims to have seen or heard. Just because you
    cannot see or hear it does not mean it is not real to your loved one. Affirm
    his or her experiences. They are normal and common. If they frighten your
    loved one, explain to him/her that they are normal.

•   Restlessness
    The person may perform repetitive and restless tasks. This may in part
    indicate that something is still unresolved or unfinished that is disturbing
    him/her and preventing him/her from letting go. Things that may be helpful
    in calming the person are to recall a favorite place the person enjoyed, a
    favorite experience, read something comforting, play music, and give
    assurance that it is okay to let go.

•   Decreased Socialization (Withdrawing From Others)
    The person may only want to be with very few or even just one person. This
    is a sign of preparation for release and an affirming of who the support is
    most needed from in order to make the appropriate transition. If you are not
    part of this “inner circle” at the end it does not mean you are not loved or
    are unimportant. It means you have already fulfilled your task with him/her
    and it is the time for you to say “goodbye.” If you are part of the final “inner
    circle” of support, the person needs your affirmation, support, and

•   Giving Permission
    Giving permission to your loved ones to let go without making him/her feel
    guilty for leaving or trying to keep him/her with you to meet your own needs

       can be difficult. A dying person will normally try to hold on, even though it
       brings prolonged discomfort, in order to be sure that those who are going to
       be left behind will be alright. Therefore, your ability to release the dying
       person from this concern and give him or her assurance that it’s alright to let
       go whenever he or she is ready is one of the greatest gifts that you have to
       give your loved one at this time.

   •   Saying Good-bye
       When the person is ready to die and you are able to let go, then it is time to
       say, “good-bye.” Saying “good-bye” is your final gift of love to the loved one
       for it achieves closure and makes the final release possible. It may be helpful
       to lay in bed with the person and hold him or her or to take the hand then
       say everything you need to say. It may be as simple as saying, “I love you.”
       It may include recounting favorite memories, places, and activities you

       It may include saying, “I’m sorry for whatever I contributed to any tensions
       or difficulties in our relationship.” It may also include saying, “thank you
       for...” Tears are a normal and natural part of saying “good-bye.” Tears do
       not need to be hidden from your loved one or apologized for. Tears express
       your love and help you let go.

   •   Giving Things Away/Making Funeral Plans
       Some persons wanting to keep control in their lives want to give things away
       to their loved ones and/or participate and plan their funeral in detail.
       Although this is hard emotionally on their family, it is important for the family
       to listen and be open to the person’s input. The person has already
       experienced a “loss of control” in their body and this is their attempt to keep
       some control over their life. Everyone, even the dying, should have choices.

How Will You Know When Death Has Occurred?
“Dying” may take hours or days. No one can predict the time of death, even if the
person is exhibiting signs and symptoms of dying.

Although you may be prepared for the death process, you may not be prepared for
the actual death moment. It may be helpful for you and your family to think about
and discuss what you would do if you were the one present at the moment of
death. The death of a Hospice patient is not an emergency. Nothing must be done

The signs of death include such things as: no breathing, no heartbeat, release of
bowel and bladder, no response, eyelids slightly open, pupils enlarge, eyes fixed on
a certain spot, no blinking, and a relaxed jaw with a slightly open mouth. When you

think death has occurred, call Mercy Hospice and a nurse will come to your home.
If your loved one has died, the Hospice nurse will call the coroner, funeral home,
and doctor and will assist you in any way she/he can.

The body does not have to be moved until you are ready. If the family wants to
assist in preparing the body by bathing or dressing, that may be done.

                                   Chapter 9

             Infection Control and Universal Precautions
Illnesses that spread from one person to another are called infectious diseases.
Each one has its own way or ways of spreading. Contact with infected body fluids
(such as blood, urine, feces, and mucus) or with the droplets that are sprayed
into the air when an infected person sneezes or coughs is a way an infectious
disease can spread. Sometimes, the illness can spread through an indirect link,
such as having contact with items that have been freshly soiled by drainage from
infected sores or discharges from the patient’s body openings (nose, mouth,
eyes, rectum, etc.)

Controlling the spread of an infectious disease means interrupting the way the
illness travels from an infected person to a non-infected person. For example, if you
have a cold and cover your mouth when you sneeze, you are stopping the spread
of infected droplets.

Careful personal hygiene and household cleanliness are very effective in preventing
the spread of disease. These and other helpful infection control measures are
discussed below.

Maintain Good Personal Hygiene
   •   Wash your body every day.

   •   Wash your hair at least weekly.

   •   Brush your teeth and rinse your mouth after every meal and at bedtime.

   •   Trim your fingernails and toenails weekly.

   •   Wear clean and laundered clothes.

   •   Change dirty clothing and bed linens as soon as you notice the soiling.

Wash Your Hands Frequently
This Is The Single Most Important Step In Controlling Infection

Wash your hands before:
   •   Food preparation.

   •   Eating food.

   •   Serving food.
Wash your hands after:
  •   Using the toilet.

  •   Contact with your own or another’s body fluids.

  •   Blowing or wiping your nose.

  •   Outside activities.

Wash your hands thoroughly using the following procedure:
  •   Wet your hands with plenty of soap and warm water.
  •   Work up a lather over your hands and wrists.
  •   Rub the palm of one hand over the back of the other and rub them together
      several times. Repeat for the other hand.

  • Interlace the fingers of both your hands and rub them back and forth.

Clean Contaminated Household And Medical Equipment Thoroughly
  •   Scrub medical equipment with a 70% alcohol solution or a solution of one
      part bleach to 10 parts water.
  •   Clean soap dishes, denture cups, etc., weekly.
  •   Do not use the same sponge to clean the bathroom and kitchen.
  •   Do not pour mop water down the kitchen sink.

  •   Disinfect mops and sponges weekly by soaking in a one-part bleach to 10
      parts water solution for 5 minutes.

  •   Flush body wastes down the toilet.

  •   Do not clean bedpans, potty seats, urinals, etc., in the kitchen sink.

  •   Do not share towels, washcloths, lingerie, undergarments, toothbrushes, or

  •   Clean up blood/body fluid/spills with 1:10 bleach solution. Be sure to wear
      your gloves!

  •   Soiled laundry should be washed separately in hot, soapy water and a 1:10
      bleach solution if a viral contaminant is present.

Decrease Your Exposure To People With Infectious Diseases
    •   Avoid crowds whenever possible.

    •   Avoid people who have been recently vaccinated.
    •   Avoid people with bacterial infections, cold sores, shingles, influenza, colds,
        chicken pox, measles, etc.
    •   Cover your mouth with a tissue or your hand when sneezing and coughing.

    •   Do not share food and drink with others.

    •   Do not lick your fingers or taste from the mixing spoon while cooking.

    •   Should be worn if contact with blood, urine, feces, mucous membranes,
        open wounds, or other body fluids will be made.

    •   Wash hands before and after wearing gloves.

    •   Gloves are unnecessary with casual contact.

    •   Gloves should not be reused.

    •   If contact with blood/body fluids occurs, body surfaces should be
        immediately washed with soap and water.

        Eating, drinking, applying chapstick/lipstick, or handling contact
             lenses in the patient care area could result in exposure!

Disposal Guidelines
•   Place needles, lancets, and other sharp objects in puncture resistant, closeable,
    leak-proof containers. Do not put sharp objects in any container that will be
    recycled or returned to a store. Do not use glass or clear plastic containers with
    sharp objects. Keep all objects out of the reach of children.

•   Soiled bandages, medical gloves, chux, etc., should be double bagged in
    securely fastened plastic bags before you put them in the outside garbage with
    your other trash.

•   Ask the nurse for instructions on the disposal of used bandages, tubing,
    syringes, and other wastes.

Subject              Disposition of Medications                Number MM.08
                     Disposal of Controlled Substances

Effective            April, 2010                           Supersedes January, 2009

Review Date          January, 2011


Provide guidelines for staff to ensure safe and responsible disposition of medications and
disposal of controlled substances.

1.     If the medication has not been used by the patient then the medication can be
       given to a community-based “take-back” program e.g., Nye’s Pharmacy,
       Friendship Pharmacy and Clinic.

2.     If medications cannot be given to a “take-back” pharmacy, and specific instruction
       for disposal are listed on the medication label, they will be followed.

3.     If no instructions are listed on the medication label, the medications can be
       disposed of in the household trash by taking the medications out of their original
       containers, placing them in a sealable bag or container and mixing them with an
       undesirable substance such used coffee grounds or kitty litter. If this is not
       feasible, medications can be flushed in the toilet.

4.     Controlled drugs no longer required by the patient will be disposed of by a nurse
       with witness in the patient's residence. The destruction of the controlled
       substance will be documented in the patients computer based medical record.
       The documentation will reflect the date, time, name of the drug(s), the amount
       disposed of and the name of the witness in attendance at the disposal.

5.     When a patient is using a IV pump from an outside vendor e.g., Responsive
       Solutions and it is no longer required, the pump and medication will remain in the
       home and the nurse or designee will notify the vendor. The vendor will retrieve the
       equipment and dispose of the controlled substance and document per their policy.

6.     In the event the patient or family refuses to dispose of a controlled substance, the
       nurse will document that information, including the name of the person and
       relationship to the patient, in the medical record.

7.     The agency does not keep any controlled drug or pharmaceuticals in the office.

8.     Staff is discouraged from transporting patient medications.

                             Universal Precautions
Universal precautions are practices that help prevent contact with a patient’s
blood and certain other body fluids. It is the best protection against illness
including AIDS, Hepatitis B, and some other infectious diseases!

How Universal Precautions Work
Certain infectious diseases are caused by viruses. For example:

   •   AIDS is caused by a virus called HIV (human immunodeficiency virus), which
       attacks the body’s natural defense against disease.

   •   Hepatitis B is caused by a virus called HBV (hepatitis B virus), which attacks
       the liver and can result in severe illness–even death!

HIV, HBV, and some other germs are spread through certain body fluids,
   •   blood (or any fluid containing visible blood).

   •   semen.

   •   vaginal secretions.

   •   certain other fluids–amniotic, pericardial, peritoneal, pleural, synovial, and
       cerebrospinal. (Ask the nurse for further explanation on these fluids.)

People can become infected if infected blood or body fluids enter their body

   •   a needle stick injury.

   •   a cut or break in the skin.

   •   mucous membranes (mouth, nose, eyes).

Universal Precautions Help Prevent Infection By:
Wearing gloves when:
      • contact with blood or other body fluids may occur.

       •   handling items or surfaces soiled with blood or other body fluids.

       •   drawing blood.

    Change gloves if they are torn and after contact with the patient.
    Do NOT reuse disposable gloves!

•   Use masks, eye protection, or protective face shields if there is any chance
    that blood or body fluids may splash into your mouth, nose, or eyes.

•   Wear a gown or apron if splashing of blood or other body fluids is likely.

Wash your hands and other skin surfaces immediately after:
•   direct contact with blood or other body fluids (without gloves, mask, etc.)

•   removing gloves, gown, or other protective clothing.

•   handling potentially contaminated items.

•   Cover open wounds and broken skin. Refrain from direct patient care and
    handling patient-care equipment if you have weeping dermatitis or sores
    with a discharge (unless you wear gloves).

•   Use sharps safely. Stay alert and always follow proper procedures when
    handling, using, or disposing of sharps. Gloves do not protect against injuries
    from sharps.

•   Do not recap, bend, or break needles. Deposit a used sharp immediately
    after use in an approved container.

•   Clean up spills promptly. Always use an approved disinfectant. Clean your
    work surface anytime it is contaminated with blood or body fluids and after
    you’ve completed your work.

•   Take care of soiled linens. Use leak proof bags or containers when laundry is
    wet or if there is a chance for leakage.

•   Dispose of infectious waste carefully.

•   Do not reach blindly into a waste container. If you must look through the
    trash, dump it out and search with your eyes. Handle laundry with care–it
    could contain a sharp instrument dropped by mistake!

•   Handle, label, and package specimens carefully. Use an approved
    disinfectant for any spills. Treat all specimens of blood or other body fluids
    as infectious.

•   Get help with uncooperative patients to prevent accidents. It only takes a
    slight movement to endanger yourself or the patient.
     •   Ask your nurse if you have any questions or it there’s anything you don’t
         understand. Always follow safety procedures. They are designed for your

What To Do If You Are Exposed To Blood Or Other Body Fluids
     •   Wash the exposed area immediately. Save any sharps or other items
         involved for possible testing.

     •   Report the incident. Be sure to report:
         *a needle stick injury or other cut or puncture.
         *splashing of blood or other body fluids into your mouth, eyes, or nose.
         *direct contact with a large amount of blood or other body fluids.
         *prolonged contact with blood or other body fluids.
     •   Follow procedures for testing and treatment. If you have been exposed to
         HBV, a immune globulin and hepatitis B vaccine can help prevent infection.

     •   If you have been exposed to HIV, ask your nurse or physician about
         counseling and possible drug treatment.

Some Questions And Answers
Q:       Do all gloves give the same protection?
A:       Because gloves vary in strength, fit, etc., you need to choose the type that is
         best suited for the task at hand. Ask your nurse for specific advice.
         (Remember to always wash your hands after removing gloves.)

Q:       What should I do if a glove tears?
A:       Remove the glove, wash your hands, and replace the glove with a new one
         as soon as patient safety permits.

Q:       What if I don’t have contact with patients at risk of infection?
A:       All patients are considered possibly infected. Use universal precautions
         whenever contact with blood or other infectious body fluids is possible.

Q:       What if I don’t have time to practice universal precautions?
A:       Always take time to protect yourself before providing patient care. In most
         instances, you can predict possible exposure to blood and other body fluids.

                                   Chapter 10

                     Lifting & Moving Patients Safely

Assess The Situation First
   •   What are the patient’s abilities and limitations?

   •   What is his or her condition? What are his or her vital signs? Are there any
       bandages, IV tubes, etc., to consider?

   •   Is he or she strong and flexible enough to help?

   •   How much does he or she weigh? Can the patient bear any of his or her own

   •   What are his or her mental abilities? Are these affected by medications? Can
       he or she follow directions?

   •   Does he or she have proper footwear? Is a transfer belt (also called a gait
       or walking belt) or mechanical aid required?

Assess Your Abilities And Limitations
   •   Have you been properly trained? This includes training in proper lifting and
       moving techniques–and in the use of equipment.

   •   Are you wearing proper footwear (shoes with nonslip soles)?

   •   Could required personal protective equipment affect the move?       Gloves,
       masks, etc., can affect your grip and vision.

   •   Have you washed your hands? This reduces the risk of spreading diseases.

Assess The Safety Of The Environment
   •   Even for a short move, a clear path is essential for safety.

   •   Check for potential hazards. These include:
       *electrical cords.
       *loose carpeting and slippery floors.
       *wet surfaces.
       *furniture, boxes, and other obstacles.
       *sharp edges.
       *poor lighting and blind spots.

   •   If hazards cannot be removed or avoided, plan a new move. Always think
       “safety first” before you begin a move.

Prepare For The Move
Get help, if you need it. In general, two or more people should use a “team lift” if
the patient is:

   •   considered “heavy” (generally 150 pounds or more).

   •   unable to help, due to his or her physical or mental condition.

   •   uncooperative or at risk of becoming violent.

Get The Equipment You Need
   •   In addition to team lifts, you may need to use:
       *mechanical aids (lifts, hoists, etc.,).
       *assistive devices (a sliding board, turn sheet, transfer belt, etc.).

   •   Be Sure The Equipment Is:
       *free of defects and in proper working condition.
       *appropriate for the patient’s size, condition, and type of move.

       Remember, only use equipment that you have been trained to use.

Prepare The Patient
(Moves are safer when the patient and caregiver work as a team.)

   •   Explain what will happen and why. Be sure to explain possible risks too.

   •   Give clear instructions to patients who can help with the move. Go step by
       step. For some patients, it’s best to show them exactly what they need to

   •   Ask if there are any questions or concerns. For patients who can help, also
       ask them to repeat your instructions in their own words.

Position And Adjust Equipment Properly
   •   Adjust the bed

   •   Raise or lower it close to your center of gravity. In general, this is a few
       inches below your waist.

   •   Position the head of the bed. Depending on the type of move, you may
       need to lower it flat or raise it to its full, upright position.

   •   Put the side rails up or down, as needed. Lock the wheels.

   •   Position the equipment

   •   Place the wheelchair or stretcher as close to the patient as possible.

   •   Align it properly. For example, a wheelchair should be placed parallel (or at
       a 45 degree angle) to the bed.

   •   Adjust the side or handrails as needed.

   •   Move footrests out of the way. Lock the wheels.

   •   Make needed adjustments

   •   Keep the bed and the equipment at the same height, if possible. Adjust as

   •   Make sure the patient and any helpers are properly positioned.

Always Use Proper Body Mechanics
This means using your body correctly for every lift and move. Here are some
general guidelines:

   •   Maintain your balance. Keep your feet apart for a stable base.

   •   Get a sure grip. If a transfer belt is used, make sure it’s properly adjusted.
       Position the patient’s hands properly–on your arms or around your waist
       (never around your neck).

   •   Keep loads as close to your body as possible. This helps you keep your
       balance–and reduces strain on your back and arms.

   •   Use your legs. Keep your knees bent and back straight. Lift with your legs to
       avoid back strain.

   •   Spread your feet and bend your knees. This lowers your center of gravity as
       well as broadens your base of support.

   •   Do not twist, overreach, or bend forward. Instead, change the position of
       your feet.

   •   Everyone has natural limits (size, strength, etc.) Following the guidelines
       above can help you stay safely within those limits–while making the most of
       your body’s abilities.

To Help a Patient Sit Up From Bed If Not Using an Overhead Trapeze
   •   Position the patient on his or her side, facing you. Raise the head of the

   •   Place one arm under the patient’s shoulders and the other arm over the

   •   Draw the patient’s legs over the edge of the bed. At the same time, lift the
       patient’s upper body, helping him or her to a sitting position.

   •   Encourage the patient to help by using his or her legs and arms.

If Using An Overhead Trapeze, Have Patient:
   •   Bend knees.

   •   Put feet flat on the bed.

   •   Grab the bar with both hands.

   •   Lift and pull with arms, while pushing with legs and feet.

To Help a Sitting Patient from the Bed to a Chair
   •   Lower the bed until the patient’s feet rest flat on the floor. Face the patient.
       Use a transfer belt, if needed or required.

   •   Bend and align your knees with the patient’s knees. Hold the patient by the
       belt or use an approved hold.

   •   Lift the patient–while holding him or her close–to a standing position, using a
       rocking motion. Have the patient support as much of his or her weight as

   •   Turn by moving your feet, helping the patient to do the same.

   •   Have the patient use the chair’s arm rests for support. Gently help lower him
       or her into the chair. Secure the safety belt.

To Transfer by Using a Transfer Belt
Use this device for a patient who can support most of his or her own weight.

   •   Make sure the belt fits properly–snug around the waist, but not too tight.

   •   Use the belt–not the patient’s arms or clothing–for grasping. In general, use
       an underhand grip (palms up).

   •   Remove the belt after the move.

To Transfer By Using a Sliding Board
Use this device to help a patient who cannot stand alone move from a wheelchair
to a bed.

   •   Use a transfer belt.

   •   Position the wheelchair at an angle, facing toward the bed. Lock the wheels.

   •   Have the patient place both feet on the floor. Move footrests out of the way.

   •   Position the sliding board under the patient’s thigh and resting on the bed.

   •   Hold onto the belt and support the patient in rising from the chair and sliding
       across the board.

To Transfer By Lift or Hoist
Use these devices for a patient who is too heavy or unable to help with a move.
They can be used for many types of transfers. In general:

   •   Have at least one helper.
   •   Follow the manufacturer’s instructions.
   •   Secure and check all attachments before starting to lift the patient.

Before Beginning the Transfer
   •   Make sure everyone knows what to do in advance, including the patient.
   •   Take a few seconds to mentally go through the entire movement needed.
   •   Give commands out loud (or count out loud) for each step.
   •   Move at the same time. Avoid sudden, jerky movements.
   •   Encourage the patient to help at each step to the best of his or her abilities.

Checklist for Lifting
   •   Can I handle the weight of the patient? If doubtful, get help.

   •   Is there a good base of support? Feet should be at least shoulder width
       apart and one slightly in front. Keep knees bent. Keep the patient close to

   •   Watch what you are lifting with. Use your legs, not your back. Maintain your
       back’s natural curves.

   •   Take steps to protect the patient’s skin. Never drag the patient across

   •   Check their condition and level of comfort after the move.

Help Prevent Pressure Sores
Patients who spend most of their time in bed can benefit from:

   •   Frequent turning with the use of a draw sheet. Prop with pillows.

   •   Pressure-reducing pads and mattresses.

   •   Skin lotions and moisturizers.

   •   Proper nutrition and fluid intake.

   •   Draw sheets and pressure-reducing pads may be obtained through your

Medical Equipment Use
   •   Keep medical supplies in a clean area.

   •   Secure oxygen tubing to prevent tripping.

   •   Never smoke in the presence of oxygen or use it near an open flame! Post a
       sign easily seen that oxygen is in use.

   •   Consider using a hospital-style bed with side rails.

   •   Talk with a nurse about obtaining an over-bed trapeze so that patients can
       lift themselves.

   •   Place the portable toilet beside the bed.

   •   Consider using a walker or cane, crutches, or a wheelchair.

   •   Follow all manufacturers’ directions regarding setup, use, and storage of
       any medical equipment.

   •   Do not use any equipment until you have been instructed in its use by a
       professional. If it is not working properly or breaks, do not use it! Notify the
       equipment provider and nurse immediately!

   •   Wheels on beds, wheelchairs, commode chairs, etc., should be locked when

   •   Hospital beds should be kept in low position during direct patient care.

To Use A Turn Sheet To Move A Patient Up In Bed
   •   Have at least one other person help you. Stand on opposite sides of the
       patient. (A third helper may be needed to support the patient’s

   •   Make sure the turn sheet extends from the patient’s shoulders to the thighs.

   •   Protect the patient’s head by placing a pillow against the headboard. Have
       him or her cross arms over chest and bend knees.
   •   Grasp the turn sheet at the patient’s shoulders and buttocks. Pull it tight.

   •   Gently lift and move the patient to the headboard. At the same time, ask the
       patient to help by using his or her legs to push.

To Lift And Carry A Patient (3-Person Lift)
   •   Stand on the same side of the bed, facing the patient, with knees slightly
       bent.    One person supports the patient’s upper body, another the
       midsection, and the third the legs.

   •   Have the patient cross his or her arms.

   •   Roll the patient towards you. Lift at the same time, and hold the patient
       against your chest.

   •   Step back from the bed. Gently place the patient on the stretcher.

                                    Chapter 11

                    Environment and Mobility Safety

 There is much that can be done at home to avoid falls and other mishaps.

Around The House
  •   Keep stairs and pathways clear of clutter.

  •   Be sure that stair steps and railings are secure.

  •   Do not walk on wet, slippery floors.

  •   Avoid using throw rugs.

  •   Have adequate lighting. Keep stairways well lit. Use night lights in bedrooms,
      bathrooms, hallways, etc.

  •   Proper ventilation should be available.

  •   Secure animals if necessary, especially during Hospice staff visits.

  •   Wear proper fitting shoes with rubber sole.

  •   Secure frayed edges of rugs.

  •   Locks should be on all windows and doors.

  •   Be sure that visitors are identified before allowing them entry into the home.

  •   Be sure to have a working telephone available and that emergency numbers
      are clearly visible by the phone.

  •   Don’t switch on lights if a gas leak is suspected.

  •   Contact the gas company immediately if gas is smelled.

  •   Foods should be stored properly in the refrigerator or cupboards.

  •   Use a hot water gauge (such as a candy or meat thermometer) for
      measuring the temperature of hot water to prevent scalding burns.

  •   Ramps should be used where required.

  •   Limit or avoid alcohol use.

  •   Be aware of any side effects from medications (dizziness, for example).
      Ask the nurse or refer to your medication sheet.

  •   Rise slowly after eating or sleeping. Low blood pressure can cause dizziness.

  •   Make sure there is adequate heating available in cold weather and adequate
      cooling in hot weather.

  •   Keep the nighttime thermostat settings above 65 degrees.

  •   To notify a caregiver of trouble, bed-bound patients should have access to a
      bell, buzzer, whistle, intercom, or other appropriate communication device at
      all times.

  •   Patients who live alone should have access to an emergency notification
      system, if possible.

  •   Never leave a patient alone if he/she is unable to call for help independently
      and/or leave the home as in the case of a fire.

Bathroom Safety
  •   Check water temperature before bathing.

  •   Use a rubber mat in the tub or shower and a non-skid rug on tile floors.

  •   Never leave an infant or child alone while bathing.

  •   Install or secure grab bars on bathroom walls (especially near the toilet
      and shower).

  •   Install a toilet extension seat to raise the seat.

  •   Switch to a hand-held shower head.

  •   Use a shower or tub chair. (Plastic yard chairs with backs work well.)

  •   Replace bar soap with easier-to-hold liquid soap in plastic bottles.

  •   Make sure faucets and towel bars are easy to reach.

  •   Ask for assistance getting in and out of the tub or shower.

  •   A bell, buzzer, or other communication device should be placed in the
      patient’s bathroom to notify a caregiver of trouble.

   •   Never use the telephone while bathing.

   •   Lower water heater temperature to 120 degrees to avoid burns.

Child Safety
   •   Keep small objects out of children’s reach.

   •   Be sure that small children do not have access to open stairways and
       windows. Use gates on stairways.

   •   Cover electrical outlets.

   •   Place knives, cleaning agents, and other poisons out of reach.

   •   Remove poisonous plants from the house.

   •   Put child safety locks on cabinets.

   •   Remove sharp-edged furniture from the house.

   •   Check flaking paint for lead and have it professionally removed.

   •   Make sure cribs meet the federal safety standards.

   •   Keep medicines out of reach.

   •   Keep electrical cords in good repair. Cover electrical outlets.

   •   Have a fire plan and working smoke alarms.

   •   Keep syrup of ipecac on hand to use in certain types of poisonings.

   •   Use hook-and-eye latches to prevent children from gaining entry to the
       basement or garage where dangerous products are often stored.

   •   Place all guns and other weapons in a locked closet or cupboard.

   •   Keep emergency numbers near the telephone for quick dialing in case of an
       emergency. Teach children how to dial for help.

   •   Keep small objects out of children’s reach.

   •   Be sure that small children do not have access to open stairways and

                                   Chapter 12

                                    Fire Safety

Fire Safety
   •   Locate and eliminate fire hazards.

   •   Have a fire extinguisher available.

   •   Keep electrical cords in good repair.

   •   Have smoke detectors installed on every level of the home and checked

   •   Plan ahead of time how you will escape in case of a fire.

   •   Make sure all pathways and doorways are kept clear of clutter.

   •   Be careful, particularly while cooking, with all smoking materials, matches,
       and flammable liquids.

   •   Pot handles should be turned to the back of the stove when cooking.

   •   For grease fires, put a pot lid over the flames and turn the burner off.

   •   Keep portable heaters at least 3 feet away from people and objects
       (especially curtains).

   •   Never dry clothes on heaters!

   •   Always turn portable heaters off when away from the home or going to bed.

   •   Provide large, deep ashtrays for a household smoker. Put water on the butts
       before disposing of them in the trash.

   •   Unplug any appliance that smoke or smells like it is burning.

   •   To evacuate a bed-bound patient, place the patient on a sturdy blanket and
       drag outside.

It’s best not to smoke, but if you or another member of the household does, follow
these rules:

   •   Never light up in bed, when drowsy, or when oxygen is in use.

  •   Use large, deep ashtrays.

  •   Never leave smoking material unattended.

  •   Stop smoking when taking medication.

  •   Never throw out smoking materials that are still hot or burning.

Oxygen Safety
  •   Post in a prominent place (the front door) a sign saying “O 2 in Use”

  •   Do not smoke around oxygen.

  •   Stay at least ten feet away from gas stoves or open flames.

  •   Do not use flammable products such as aerosol sprays, paint thinners, and
      rubbing alcohol.

  •   Have a fire extinguisher available.

  •   Notify the fire department and local utility company that you have oxygen.

Using A Fire Extinguisher
  •   Where you place your fire extinguishers can make or break your fire
      evacuation plan and could save your life. The extinguisher must be within
      easy reach, close to an exit, and away from potential fire hazards. You
      should probably have more than one extinguisher in your home. The kitchen,
      basement, and garage are the most common choices, but be sure to use the
      correct type of fire extinguisher for each area.

  •   Before you decide to fight a fire, follow these three steps:
      *Call the fire department.
      *Make sure everyone has evacuated the home.
      *Be certain the fire doesn’t block your escape route.

  •   If the fire has spread beyond its immediate area, do not attempt to fight it.
      By this time, the fire is too large. Your extinguisher will only last 3 to 20
      seconds and will only discharge 30 to 40 feet. Close off the area and leave
      the fire to the fire department!

P.A.S.S. Over The Flames
If the fire is small and you have decided to stay and fight the fire, remember the
word P.A.S.S.

        P     Pull the pin. Some extinguishers require releasing a lock,
              latch, or pressing a puncture lever.

        A     Aim low. Point the extinguisher nozzle (or its horn or hose) at
              the base of the fire.

        S     Squeeze the handle. This releases the extinguishing agent.
        S     Sweep from side to side. Keep the extinguisher aimed at the
              base of the fire and sweep back and forth until it appears to
              be out. Watch the fire area. If fire breaks out again, repeat
              the process. If you are fighting a floor fire, sweep from the
              edge in. For wall fires, sweep from the bottom up.

         ** Remember to stay low, away from heat and smoke.**

Keeping Current
Maintenance and inspection of your fire extinguisher will assure that the
extinguisher will perform when a fire occurs. A quick check of each extinguisher
should be done monthly to look for damage. A thorough examination should be
done at least once each year. Ask yourself these questions:

   •   Is the extinguisher easily accessible and in its proper location?
   •   Are the operating instructions visible and facing outward?
   •   Is the extinguisher fully charged?
   •   Is there any corrosion, broken seals, or damage?
   •   Are all connections between the hose and shell secure and free from
If the extinguisher is reusable, be sure to have it recharged after every use. If the
extinguisher is a disposable model, it can be used only once and then it must be
replaced. Be sure you know what type of extinguisher you have so you can count
on it to work when you need it.

Always remember, if you’re not sure how to use a fire extinguisher, don’t try. The
time you waste could mean the difference between minor damage and major

disaster! It’s time you can’t afford to waste once a fire has started–so sound the
alarm and evacuate!!

Know The Different Types of Extinguishers
There are five basic types of fire extinguishers. Each is used for a different type of
fire. If a fire breaks out and you’re not sure which type of extinguisher to use,
don’t panic. Call the fire department and get everyone out of the area. If you try to
fight the fire with the wrong type of extinguisher, you may make it worse. Let the
experts handle the fire.

The following describes the various types of extinguishers:

      For combustibles like wood, paper, cloth, rubber, cardboard, and any
      plastics. Type A extinguishers are filled with water and will cool the fire.
      Never use this type on a cooking fire or an electrical fire. The grease
      from a cooking fire will scatter the flame and the electricity in an electrical
A     fire is easily conducted through water.
      For flammable liquids such as gas, grease, oil, paint, tar, and lacquer. These
B     extinguishers are filled with carbon dioxide and will smother the fire.
      For electrical wiring and equipment like fuse boxes, circuit breakers,
      appliances, and audio/video equipment. These extinguishers are filled with a
C     dry chemical and will smother the fire.
      For combustible metals like magnesium, titanium, zirconium, lithium, and
      sodium. These extinguishers are filled with liquefied gas that reacts
      chemically to fire. If you do encounter a fire like this, be sure to let the
D     firemen know so they can handle it properly.
      For Type A, B, or C fires. The extinguisher is filled with a multipurpose dry
      chemical that will smother the fire. Type ABC extinguishers tend to be the
ABC   most popular because of their multiple uses.

Another way of helping us is to become a Hospice volunteer. The agency depends
on volunteers to assist in the office or visiting families who are experiencing the
same situation you have experienced. Volunteers are integral to our mission of
compassionate caring. Call our Volunteer Director who can discuss this way of
participating in our mission.

We can use help in getting the Hospice message out to those who may not need it
today, but could use these services sometime in the future. We need invitations for

a Hospice representative to speak to your civic, community or religious group. We
want to talk about the Hospice mission so that the community understands that
dying is about living. We make presentations on many topics and can address
issues that are important to a particular group. Our Community Educator would love
to hear from you if you can connect us with one of the groups in which you are a

Thank You
We thank you for the privilege of assisting you with the care of your loved one. We
salute you for all you have done to surround your loved one with understanding
care, to provide your loved one with comfort and calm, and that enable your loved
one to leave this world with a special sense of peace and love.

You have given your loved one the most wonderful, beautiful, and sensitive gifts we
humans are capable of. In giving that gift, you have given yourself a wonderful gift
as well!

                          Summary of Information
I, as the patient/care giver, have received the following information. I understand
these aspects of Hospice care and I will review them periodically with the Mercy
Hospice staff during home visits.

      Patient Bill of Rights

      Mutual Goals

      Complaint and state hot line procedures

      Medicare/Medicaid charges for Hospice services

      24-Hour emergency RN contact service

      Hospitalization policy and my responsibilities

      Hurricane evacuation procedure and my responsibilities

      The names of the staff members that will be working with me

      Advanced Directive, EMS DNR, and DNR instructions

      Medication coverage

      Medical equipment coverage and specific suppliers

      The important of 24-hour care giver availability and a plan of action when I
      am no longer able to care for myself.

      Teaching about signs and symptoms of approaching death.


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