Ep. 21 | Eli Metts, NP, Hospice of South Georgia

Transcript

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- Welcome to another episode of What Brings You in Today. I'm Erika Bennett. And I'm Taylor Fisher. And we just wanna thank everyone for tuning in to our series. And if you haven't already, please like and subscribe.

- And if you have any questions or topics that you would like us to cover, you can submit those at sgcm.org/podcast.

- Awesome. And today we are joined by Eli Metts, nurse practitioner, and he works for our Hospice of South Georgia and Langdale Hospice House. So, Eli, what brings you in today?

- Well, I'm here to talk about end of life care and I'm specifically about Hospice of South Georgia and the services we provide to the community.

- Very good. Hospice. I feel like I've been in healthcare for 12 years now and it does, there's a lot of misconceptions about hospice. So first of all, tell us what, who you serve and kind of just the general s spill that you give to anyone that might be looking for your services.

- So when you think about hospice, the, the, the patient population we serve are patients who have a life limiting illness or condition. And it's really challenging to think about because when hospice was originally created in the eighties, it was really for cancer patients primarily. And it was also kind of created or formulated as a benefit from Medicare and Medicaid for the AIDS epidemic because at that time, if you had AIDS it was a terminal condition, it was not curable. And really life expectancy was pretty short. And so today we serve a variety of people with a variety of different conditions. Any condition that is eventually incurable, progressive and eventually will be fatal. And it doesn't mean that you couldn't have this condition for decades or years before coming to hospice. 'cause you can, you think about dementia, congestive heart failure, COPD, these are things you can live with and treat for many, many years. But when they enter their, what we call their terminal phase, the latter stages of that disease trajectory, that's when it's time to think about end of life care. Hospice is really identified as when someone is based on a physician certification of their illness stage. We anticipate that if it runs its normal course, the disease may take their life within six months. I will tell you plainly and clearly that we have plenty of patients that live with us for a year, two years. I can think of a couple patients that were on hospice for four years.

- So

- That's not a universal Right rule and it's not a universal as far as estimating life expectancy because that's very much an educated medical guess. But that's the population we serve. We serve a variety of different people based on whether they're Medicare recipients, whether they have private insurance, all ages from birth to death. We serve people because we're the only not-for-profit hospice in the region. We actually serve people regardless of their ability to pay. If they're underinsured or uninsured or maybe they're out of network, we take them if they need end of life care, no questions asked. So that's the population that we serve. We also have a palliative care division. Palliative care is like a step before hospice. And we see people that are still seeking curative disease, modifying life prolonging care. These are people that still wanna see their family doctor or their specialist. They may wanna come to the hospital if they get sick. Normally that's not the case for somebody once they elect the hospice benefit. So we have that as kind of a subspecialty of ours that that falls under the Hospice of South Georgia umbrella.

- What would you say are like the majority, are most patients referred to you directly from a primary care or most patients from the hospital setting?

- Great question. So a lot of our referrals, the vast majority I would say at this stage do come from inpatient. Here at SGMC Health, we have an inpatient palliative care division that sends us a substantial amount of referrals. I should back up. Probably not the majority come from the hospital, but it's gotta be close to 50 50. And then a variety of other sources. Primary care doctors, specialist, you know, like a, a cardio cardiologist or a pulmonologist or a variety oncologist, cancer doctors. We get referrals from home health agencies because maybe they're seeing somebody who is getting home health services in the home, but they're just not doing well. They're declining over time and they need something different. Also, community and self-referrals, family referrals or somebody calling up and saying, Hey, I'm not doing great. My brother was on hospice with y'all. My mother was on hospice with y'all. And I think it's time to talk to you and get an explanation of services. So you actually do not have to have a physician's order or an official referral for hospice. It is a benefit that you're entitled to that does not require anything except usually our medical director, Dr. Hobby, signing the certification of terminal illness and saying, this person is terminally ill. This is the primary diagnosis that makes them eligible. And they can elect hospice without a physician's order or a referral.

- My father-in-Law, he had lung cancer and he went through cancer treatment, had to have a large portion of his lung removed during that time and actually overcome the cancer treatment. But then, which had several involved, several rounds of chemo, just a very long, very hard recovery. Right. And just process. And then he ended up getting pneumonia in the hospital later on. And because of so many things that had happened, you know, he just, it just wasn't, you know, we didn't feel he did. He had already told us very clearly, you know, he was ready to go to heaven, move on. He had felt he had lived his life and, and he hated being in the hospital. You know, he was one of those that would never get carried anyways. So then being in the hospital, we, we just knew he didn't wanna be there anymore. And I remember, you know, they had recommended potentially like a home health nurse, but we knew in his situation, the doctors, I mean, told us, they were like, he's, you know, he's got all of these, his heart's starting to fail. A lot of different things were, it was not looking good. And so I had known about hospice just from the relationship that we have with y'all and called out and was like, I really think we probably need to consider this and let's look into it. And we reached out to hospice. They were able to talk to my mother-in-Law and get him home

- Where

- He could then spend, I mean, I think it was probably less than a week that he spent home. But during that time, he was able to be in his home with his children. And that meant so much to the children and to us and the grandkids, you know, being able to see him. But we knew it meant a lot to him because we knew he really hated being in the hospital. 'cause most men don't like that anyways. But, but anyways, just having that personal connection to see your team work in action and see kinda what they do it, that's a tough talk about like what the, what y'all have to deal with as professionals and caring for hospice patients. I mean, truly angels on earth because you have to see people some at their like worst times and or maybe some of them at their best times, but

- Sure. Well, and I think the thing that we have to always remember, and I try to do this and I feel like all the team does. We do this every day, but the patient and the family do not. And a lot of times it's their first experience going through dealing with death and dying. That's tough stuff to talk about. It's very emotionally distressing and challenging. And, and you know, it's something that as a culture we don't talk about usually until we have to.

- Right. And, - And so I think it's really helpful to hear that story because it reminds me, it, it's such a common thread. You know, I don't wanna go back to the hospital. I've gotten good care at the hospital, but I'm just done. I want to go home. Yeah. I want to maximize the time I have left with my family. And, and I think the thing we do really to establish, you know, d trust and determine the patient's need is the first thing we do is we go in and we say, what are your goals for your care? Because we're stepping into their home. We do have a certain amount of patients that are in assisted living or at the hospice house or skilled nursing facilities. But, but most of our people are in their home and we're on their turf. And so we, we go in and we try to say, how can we meet your need? What's not been going well in your healthcare that makes you now, you know, choose to elect hospice to look for something different or something better? Because if we can't cure the illness and if we can't ultimately change the outcome, how can we get somebody there with comfort and dignity

- Yeah.

- And peace. And most of the time that's found in their own home.

- Yeah.

- If you ask people where they want to die, they wanna die at home. If you look at the statistics where people die today in America, the vast die in nursing homes and hospitals. And although they may get excellent end of life care there, it's just usually not what people would prefer if they could speak for themselves. So it's a great way to get somebody home with the support they need and to empower their family to provide care. Home health is, is good too, but home health is there meeting a need, usually a rehabilitative or curative need. Right.

- Hospice

- Can give you a lot more because kind of everything's covered. You have this whole interdisciplinary approach that I'm sure we'll talk about. And I don't know, it just, it's, it's, it doesn't have to be what people think it is.

- Right.

- You know, it can be really beautiful if done correctly.

- Yeah. So let's talk about how you work closely with those families during that difficult time. Like what is your role and, you know, the nurses and whoever else, I don't even know who else is on your team, but what is their role during that time?

- So I'm, I'm super glad 'cause I need to tell you who's on the team. 'cause it's so important. It's hospice is not just based on the medical model or the nursing model. It's a true interdisciplinary, you know, multi-professional team of people that come in and support someone because death is not a medical event. You know, the care we provide and the things we do in regards to medications and symptom management and, and all those things are medical or nursing in nature. But we have social workers, we have chaplains, we have nurse aides, we have volunteers, we obviously have registered nurses and LPNs. We do, we do music and pet therapy and things like that for people. You know, and, and we just have a, a whole team of people that come in and support the whole person because in end of life care we think it's holistic and it's person centered. It's based on their goals of care, not ours. We, we kind of step in and we take a backseat approach and we try to educate and empower people so that they can do, you know, what's important for them for whatever time they have left. Whether it's a week, a month or a year. The social workers are really uniquely skilled. All of our social workers are masters prepared, licensed social workers. They can help people tremendously process the psychosocial and emotional issues. They can do individual one-on-one therapy. We have a bereavement program for people that's available for 13 months after their loved one dies to get them through the anniversary of that death. That's super important. They can do individual grief counseling and group counseling with other people who've lost loved ones. Our chaplains support their spiritual needs and, and, and determine what those are and help them be met in the home. And sometimes that's linking them with other people in the faith community, you know, that align with their specific faith practice. You know, maybe bringing them in to perform some ritual that's important at the end of life for them. Our nurse aides come in and provide the personal care and help with bathing and cleaning. And they can come in several times a week to assist the family with caregiving. Registered nurses come in and, you know, the day-to-day assist assessment, triaging of symptom symptoms, medication management, they order equipment supplies and meds. They talk with myself and other members of the medical team to, to make sure they get excellent care. Volunteers are a big part of our service and they are just phenomenal because obviously they do what they do out of love, not out of a desire for payment. And we just have a whole host of people in the community that really are involved in the care of our patients, whether they're at home or the hospice house. And I think it's really, it's a unique arena of healthcare to be in as a provider because although the medical team is kind of overseeing the actual healthcare delivery and the management of the patient, we're not overseeing everything. It, it's a holistic approach for sure in hospice.

- I like that. Yeah. And it's a whole different aspect of healthcare, truly. Right. I mean, because it's, it's not the we're here to save your life part that people mostly think about healthcare. It's, we are here to make the, your life the best it can be while you have it Right. And to be on your terms and what a powerful like calling and job that y'all have.

- It's very rewarding and fulfilling. And it's not what people think it is. It's not what I thought it was because, you know, when I went over there as a registered nurse, I had no idea what end of life nursing and what end of life healthcare looked like. I had a a pretty, I would say a pretty good misconception actually of what it was. And it, it's not depressing. It's, yeah, it's the most rewarding job I've had in healthcare. I absolutely love it when you tell people you love hospice. They kinda look at you sideways. But it's really, it's really amazing when it's done correctly. I like to think our agency does it better than any other, I'm biased, but you know, I know we do some things that other agencies don't and we really put the patient and the family at the center of

- Care. I would think it's a tremendous honor to be chosen to be with a, a person in their family when they are at the end stages of their life because they're really trusting you with so much. Not just the care of their loved one, but the whole experience, their dignity and you know that they're gonna have that memory forever.

- Sure. They're inviting you into probably the most emotionally challenging and vulnerable period of their life. You know, and they're, and and they're looking to you for, for guidance and your expertise. And again, the thing that I think we do a great job of is, is giving them the tools. 'cause we may only be there, you know, the nurse or the social worker or, or the nurse aide. They may be there for an hour or two

- Once - Or twice a week based on the patient's condition. But other than that, the care falls to whoever is in the home. And, and some of our patients obviously are, they walk on their own. They toilet themselves, they feed themselves. Some require significantly more care as their condition progresses. But what we're there to do is to empower them and enable them and say, here's how we can help. And when you do that, what you also do is you make people's grief less complicated because they never thought they could do what they end up doing. Yeah. They're like, we didn't have any medical training. We had no idea what this was gonna look like. And the hospice team came in and supported us and they made it a really beautiful experience. Most of the time what we hear is we wish we would've chosen hospice sooner. We did not know what it was. And we had some pretty grave misconceptions about it. What, what it

- Was. And what are some of those misconceptions that the community can have about hospice? Sure.

- Well, the one, there's, there's two that really stand out to me. And I think the first one is that hospice is for the very last hours and days of life. As I said earlier, we have patients that have been on services for years, you know, and when we get somebody that only has hours to days left to live, we really have very little opportunity to impact them.

- You - Know, we're kind of in a crisis mode at that point, and we do our best. But the more we can prepare and plan, and again, empower the better the family and the patient's experience is. So it's not for the last hours and days only. It's good to catch people early. Therefore, it's good to have early conversations like this and get some of the word out about when hospice can be elected. Not just when somebody's in the active dying phase. And I think one of the other big misconception is we just quit treating them and we take 'em off all their medicines and we give them morphine to hasten their death. And I bring up that specific medication because it's just one that's kind of a, a dirty word in healthcare. And it's, and it's, it has a connotation of being used at the end of life. And we have to do a lot of education that we don't come in and give medications that hast and death. We give medications for symptom management and comfort. And one of the reasons it's certain medications that are used for pain or shortness of breath, such as morphine. One of the reasons they're equated with death is because a lot of times symptoms emerge at the very end of life that require that type of medication

- And

- That type of treatment. We don't take people off of all their routine medicines. We continue to manage their chronic health conditions.

- Right.

- You know, if you come in and you're on a, a, a cholesterol lowering medicine or a medicine for your diabetes or a blood pressure medicine, we will continue those. I prescribe those, we manage them. And we never say, you have to quit taking this. You have to quit taking that. Furthermore, we don't ever say that you have to quit seeing a certain provider. If it's important for you to maintain a, a relationship with a doctor who's been involved in your care for many, many years, you can do that. Hospice is also a choice. And so one of the other misconceptions is once you sign up for hospice, you forego everything else in primary or preventative or curative healthcare. Hospice is a choice. You can also choose to revoke or ascend from hospice and go back and, and receive assertive curative care at any point. Sometimes we have people that because of the light really close, you know, manage care of hospice, they stabilize and they improve very often with things like cancer or other diagnoses. That's not so much the case. But there are conditions which people can improve and stabilize and they think, you know, I think a little more treatment under the care of someone at the hospital or in a specialist office could maybe extend my life, maybe help me meet a goal. Maybe they're trying to just live six more months to get to their granddaughter's wedding or graduation and, and they go back and seek that care and they can do that and they can come back to hospice. It's a choice to elect hospice. It's also a choice to come off of hospice if it no longer aligns with your goals. So I think people need to know that. Yeah. Once you sign up for hospice doesn't necessarily mean you have to die while on hospice.

- Right. Very good points. I think the other thing that's unique to your organization, hospice of South Georgia, is that they have the inpatient hospice house. So tell us a little bit about that.

- I'm so glad to talk about the Langdale Hospice House because it's a very important part of what we do. It makes us, it sets us apart in the sense that no one else in the region, because there's several other hospices in our service area, which is an eight county service area, none of them have an inpatient facility. And so it kinda limits sometimes when you have somebody who has really bad symptoms or something that needs to be stabilized in the inpatient environment. A lot of other hospices, unfortunately, their patients may end up going back to the hospital because they just can't get that close skilled nursing care around the clock that they need. So they may have to go to the hospital to seek that, even though they don't want to. Right. They'd rather be managed in a more home-like setting or by hospice trained staff. So the Hospice house allows for that. There are a certain amount of people that live there under, that are called residential level of care. They're, they're active hospice patients, but they stay there. They live there with us. And then the other end of the hospice house is more for this acute symptom management population that I'm alluding to. And also we have respite patients that can come in, let's say you're providing care for your loved one and I mean you just, every, every month you probably reach a breaking point.

- Yeah.

- 'cause or you know, they can come in for just scheduled respite. Like they need a break five nights at a time.

- Yeah.

- Or they can come in because you've suddenly had your own medical event. Right. Perhaps you had to go to the hospital. Perhaps you're having a procedure done or you're traveling out of town so your loved one can come in and get care there and then return back to their home environment. But really what I, what I enjoy the most, and a big part of my responsibilities is to oversee those GIP patients on a daily basis. That's, that's the ones that are there for, it's kinda like critical care of hospice. We bring 'em in, we stabilize a symptom. Maybe it's intractable pain, maybe it's shortness of breath, maybe it's a really bad wound that we're trying to stabilize and start a new treatment. The goal may be to get them back home and after we stabilize the symptom as an to hospitalization or sometimes they come there and these symptoms are occurring at the very end of life. And so we know that what they're there for is to get good symptom management as they pass naturally. It takes that burden off of the family.

- Yeah. And it

- Puts it in the lap of skilled nurses who are hospice train. And I've just seen some really beautiful outcomes there. You know, as, as an alternative to like, what else are they gonna do? Right. If they don't have the hospice house, it either falls to them in the home or a lot of times they end up coming back to the hospital even though that wasn't their wish.

- And the hospice house, I've been there and toward it and stuff. It doesn't look like a hospital

- Intentionally.

- Yeah. It's beautiful. It's very comforting environment. Very calm and serene and peaceful and

- Yes, - I mean, I think it definitely sets the stage for a, a just calm event and just peaceful, I guess. Yeah, absolutely. As much as you, as much as it can be. Right.

- Well that, and that's the point. It's homey. It's, you know, not a lot of lights and alarms and it, it doesn't have that kind of, you know, sterile feel of an acute care hospital. And it's all about, it is, it's about comfort and dignity and peace for the family during that time and the patient.

- Yeah. I'm sure over your time that you've been with hospice, you've probably treated so many patients and seen so many families. Are there any that stick with you? I mean, I'm sure a lot of them do, but any particular story you might wanna share that was, you know, a really beautiful outcome or good, you know, feeling or anything like that?

- There's so many, you know, obviously a lot of the unusual cases stick out, you know, like with young people, which are always really tough. But I, I think one that I would probably wanna highlight would be kind of related to our, our ability to serve people regardless of their insurance status and stuff. And I remember there was an, an undocumented migrant that worked locally here that developed a terminal condition and was in a living situation where it was, you know, it was really just a bunch of guys that were also migrant workers in this area that there wasn't, there wasn't gonna be a dedicated caregiver for this individual as their health declined and as they progressed closer to death. And I just remember, you know, there being a, a language barrier there, this individual from Central America. And I just, I always think about this particular case because we brought them into the hospice house for symptom management like we were just talking about. And they ended up staying there until they passed. But in that time we were able to use translation services and we had some staff members that spoke Spanish. We were able to get a Catholic priest in there, you know, to perform last rights and do things that were important. We were able to establish a line of communication with the family back in their country of origin. And all this happened knowing that we would never receive a dime of payment from any insurance source. He did not have the ability to pay for the residential level of care, which is an out of pocket room and board expense. But it was the right thing to do for someone who otherwise would've had a bad death or a symptomatic death where they were living. And there was really no one there, especially during the day when everybody was at work to help provide care for this individual. So I just think about that as being really, really cool and something that you would not see if we were purely driven by profit motives, you know, being partner with STMC health and being part of a non-profit organization. We can do those things because people deserve death with dignity, whether they can pay for it. Right. Or whether you can bill for it or, or not. So I get a, that one's a little special to me. And I remember that. I'll never forget that when it was a very unique case and something I'm supremely proud of to this day.

- Of course. I think that, which I didn't know before I started working here. People probably don't know that that is a, a thing that hospice offers is the treatment without necessarily having the ability to pay. And that's funded through, you know, the foundation or you know, and donations from the community. And Erika probably knows more about that than me.

- Yeah. I mean, just from our health system too, is the same way. But specifically hospice being unique. And that is the only one that is a not-for-profit in our area. I mean, that is the, our mission is to improve the lives of all we serve. And that's regardless of their ability to pay.

- Because

- How can you neglect someone in that time of need? I mean, it's just not, that's not our mission. That's not your mission. It's not our mission. And I think that's important to think about when you're choosing your healthcare services is where their heart is.

- Yeah. And, and, and I know that I've seen it play out time and time again. That's not the only individual that, that fell into that category, but we're able to do that without pause or hesitation 'cause it's the right thing to

- Do. Right. Yeah. And I know we have a lot of donors that

- We should

- Yeah. Throughout our community. Because once they experience or the hospice themselves or have a family member or someone and they see how y'all act with the families and they know what it means to them and they wanna give back to that service because it's so impactful to them. And I think that speaks volumes too to what you do is that you have so many community members who do step up to support hospice because they are fully behind what y'all do.

- Yeah, we certainly do. We have a lot of external funding and donations for people that their families receive services with us or not just, you know, that know that it's a need that, that, that that needs to be met. We also have the tree house thrift store that, that funds our care, indigent care people that cannot pay for services. So yeah, we are, we're very fortunate. We're the longest lasting hospice in the area. You know, we've been around since the late eighties. Started in a little volunteer closet Yeah. Here in the hospital with just a couple, couple of staff

- Members. Were we first were hospice, were, I mean, I think we in this area.

- In this area, yeah. After the benefit was created and stuff. So, and I, and I'll tell you where I, I like to think we're the best, but it's because of things that we do. Yeah. Again, without giving any consideration to how it impacts our bottom line, it's the right thing for the patient and the family.

- I think it's gotta be, it's truly a calling for the, the staff that works in hospice. You know, the nurses and volunteers and you know, yourself and everyone that works there. 'cause that's a really difficult job.

- If it's not you, you won't last an end of life care. You have to, it is somewhat of a calling. You have to find the reward and the fulfillment in it. It's very emotionally challenging. You have to really watch out for, you know, getting compassion fatigue and getting desensitized when you're exposed to death and dying. But that's true for any arena of healthcare in the hospital. Critical care in the emergency department, you know. But we really are careful with it. We, our social workers and our bereavement counselors sometimes counsel our nurses as much as anyone else or our other staff members. We do a patient remembrance ceremony every week where we talk about the patients who have died in the last week. And we just share some things that the rest of the team who weren't maybe in their home as part of their hospice team would not otherwise know about them. Things that aren't the obituary. And those are really cool ceremonies.

- Wow.

- And, and, and just supporting the staff and making sure, hey, we keep the main focus, the main focus, patient-centered care, holistic care. It's not our plan, it's theirs. And how do we make this as good an experience as it can be. It's emotionally tough enough already. What can we take off the plate for these, for these individuals and their loved ones.

- So what would you say to somebody who was considering hospice, either for themselves or for their family member? Do you have any advice for them if they're kind of on the, you know, teetering of what they should do? Yeah, and go

- Ahead. You do that. I mean, I want you to answer that too, but also do you tend to have more people, patients that say, Hey, I wanna be on hospice or family members that are like recommending the hospice for their patients?

- I'll answer that first. Okay. I think a lot of times patients may be on board before families.

- Right. - You know, we've seen that plenty of times. Or you know, it may be where the patient is incapacitated and they can no longer make their own healthcare decisions. And the families are struggling with, is this the right thing to do and is this the right time? We hear a lot, you know, oh, we're just not ready for hospice. Yeah. And, and I, I, I don't argue with them, but I'm looking and, and I'm reviewing the records and seeing the trajectory of this disease. And I'm saying, I, I think you've been ready for hospice and I know the, but, but I have to focus on what can we provide for you? Let me tell you what it can do and what it's not. But a lot of times families feel that it's giving up,

- You - Know, and it's sometimes framed that way. They think hospice is giving up, but it's not. Because if the end result is the same, again, it's how do we get there?

- So - Sometimes families struggle, right? Yeah. We don't wanna give up on mom or dad or spouse. We certainly don't wanna give up on a child. And those are the unique and toughest cases we deal with. But how do we get there if the end result is the same, you know, how, how do we get there? And sometimes I think hospice makes a big impact when somebody's considering hospice. The most important thing to do is your research, your homework. Find out does this hospice, number one, is it, you know, aligned with however we're insured, you know, what services are provided? What is their staffing model? Do they have a dedicated on, on-call nurse? You know, how do they get ahold of their medical providers after hours? What are my options if I go into a symptom crisis and I need stabilization and we don't wanna go back to the hospital, what are y'all gonna do? And, and looking at the hospice compare data, you know, there's a lot of stuff out there with surveys are conducted and just seeing, you know, what, what the statistics say, talking to people in the community. I have no reservations in recommending that. 'cause I know what our, I know what our quality scores are And they're super high in every category and I feel great about that. But, but definitely do your own research. And if you even think based on the diagnosis that you or your loved one has that you may be considering palliative or hospice services or any kind of end of life care in the future, start looking at it now. Start having those conversations now. Don't do it in a moment of crisis. Don't do it during a hospitalization even. I mean, if you have to, you have to. But have those conversations early. Put some things on paper. Decide who you want to make your decisions. If you can no longer make them for yourself. You know, advanced care planning, I can't suggest enough. It's important to have these conversations as uncomfortable as they are before it's absolutely necessary. Yeah. If that makes sense.

- It does. I think that's great advice. Oh, all right. Well I think that wraps up our time. But I mean, you did awesome. I mean, the content is, I mean, I think it's so important for families to hear, and especially here before they, like you said, before you, before you necessarily need it. So that when, that if that when, and if that time ever come, you have, you're equipped, you feel comfortable with what you're doing. So thank you, of course. And the entire hospice team for all the good work that you do.

- Thank you.

- Yes.

- And thank you for being here today. And thank you to our listeners for tuning in. And we would just like you to make sure you like and subscribe so you can get new episodes every week. And if you have any questions, please feel free to submit them at sgmc.org/podcast. Thank you.