I had a patient that I was called to assist with today. This patient was a 90-year-old with end-stage COPD. She has been admitted to home health originally by me for wound care and PT/OT needs. She had been falling, having breathing issues, and declining over the last few months. She had one rehospitalization shortly after admission to home health for severe COPD exacerbation, difficulty breathing, and had been sent to the ER.

During hospitalization, the patient still wanted to continue to be treated, a new ASV machine was ordered, and she was sent home again with home health. This time only with orders for PT. The PT notified the HH RN of the need for wound care. The nurse, seeing the patient, contacted the RN while she was at the home. The patient looked the same as the last time she had sent her to the ER, struggling to breathe, lethargic, not responsive, oxygen sats in the 60s. The HHRN case manager arrived to find an actively dying patient. She gave the husband and patient options to call 911 now, or we needed to find a Hospice team. The spouse and the patient were unsure of what to do. RN CM called children who stated, “My husband and I are on our way, but we want Hospice, not ER.” I asked if they had a preferred hospice company, and they said your team is who we want. I messaged the manager and the Hospice nurse for my area, Laura Smith, to ask about available support. Laura has always been responsive to everything I have ever needed. Laura stated, “I’ll be there in 30 minutes”. Laura arrived within 30 minutes and was there when the family arrived to make the ultimate decision to admit to Hospice. Laura took care of everything from there. She educated, assisted with meds, and supported the family to care for their wife and mother at home. Laura also notified the HH team of her death later that evening.

I have tears in my eyes writing this because I am so grateful to know that I have Laura on my team. It was so nice to be able to transition her right over to hospice at her time of need with no gap in care. I know this was because Laura Smith dropped what she was doing to help me, our patient, and her family out. I do not call for help often, but when I do, I need it. Please recognize Laura Smith for being there, most importantly for the patient and the family, but also for me as a team member.

This is not the first time Laura has helped me transition patients to hospice. I feel very safe knowing that she is the partner in my zip code. She keeps me informed and involved, and I trust Laura with my patients.

Laura, whenever I see you, I hug you because I know a good person when I meet one. Please know that you are so valued, so special to our patients, and are an angel on Earth. Just one of many examples of Laura's dedication to her patients and the care our hospice team provides.