I am an RN Transitional Care Manager. My job is to specifically visit and manage our frequently admitting patients and assist with interventions in the community to assist the patient.

I send at least 1-2 patients onto palliative care and or hospice weekly. Sometimes, patients will decline, transfer to ICU and expire.   In previous roles, I have cared for actively dying patients as a CNA and LPN. Personally, I have provided end of life care with my family for my grandmother, and my own mother. For me, being with a person during their last breath is a difficult thing to do, but a priviledge to be with someone during their last moments. I have found my family members, as well as patients, are often ready for suffering to end. I find a person’s preparedness, family, and faith greatly affect the dying person’s approach to death.

Depending on their needs, I assist families and patients find resources to address the root problem. This may be from coordinating care at home, to applying for benefits, or volunteer and community services. Many I have seen over mutliple admissions. For high risk patients with chronic and terminal illness, I specifically incorporate consults with spiritual care, and a strong palliative care/hospice provider.  The palliative care providers I recommend  send  Nurse Practioners bedside to the home every two weeks, or more often as needed (many palliative programs only have “telephonic” support, which is not enough support for many high risk patients). This strong “prescriber” relationship significantly reduces our re-admissions, along with improving education to patient and family about their condition, and the services that palliative care and hospice can provide them. Despite fear, through the interaction with our team regularly supporting  patients during the final “season” of life, families often are relieved of some of their guilt and stress on caregiving burdens. Often, families state they wish they would have known about these services earlier  (Hart, 2014).

From my personal and work related experience, I do not fear death. I have Advance Directives prepared and copied to my family, and we often revisit health topics and our wishes. The more I see at the trauma hospital where I work, I fear more about long term disability and financial resources running out and quality of life deteriorating. I have seen to many people drag out the inevitable, leading poor quality lives and being unhappy. For me, quality is better than quantity. I continue to live modestly, maintain an accessible home, and keep resources available for times of need. When the my time comes, I will not be afraid to reconcile and meet my maker.


Hart, J. (2014). Shifting Our View Toward Palliative Care’s Life-Giving Role. Alternative & Complementary Therapies, 20(1), 31-33. doi:10.1089/act.2014.20106

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