Caring for Patients as a Hospice Nurse

Podcast Transcript

Carol Pehotsky (00:04):

We all probably know the phrase attributed to Benjamin Franklin that, "Nothing is certain except death and taxes." And while that's probably true in most of our lives, our exposure as nurses to and comfort supporting patients through end-of-life care is certainly limited sometimes, or variable. I'm joined today by Ashley Clifford to learn more about her passion for hospice nursing.

(00:27):

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing from patient care to advancing your career to navigating tough on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

(00:48):

Welcome back, everyone. Way, way, way back when I was in nursing school and that's way back when, that was the early days of whereas nursing students we were able to do some internships and some experiences with nurses in the field to supplement our clinical time. And I had the great fortune, during our home health course, to have that opportunity to do that. And, you know, put my name in, submitted my application and they matched me with a hospice nurse. And, you know, I think all of us as nurses have sometimes said, "Oh, I could never do that," and I walked into that experience thinking, I- I don't know that I could ever do this. And what a gift it was to spend that time with that nurse, 20+ years ago. And-and, you know, knowing how much it's probably evolved, but just really, it's still a core memory for me, whether we were going into people's homes or whether we were going into the hospice center, just how fascinating and different but meaningful her nursing work was. And it stayed with me all these years.

(01:44):

And so today it's my great pleasure to welcome Ashley Clifford to the podcast. Ashley is a nurse case manager with Cleveland Clinic Hospice Care. Ashley, we're so glad to have you on the show. Welcome.

Ashley Clifford (01:53):

Awesome. Thank you so much for having me, I'm excited to be here.

Carol Pehotsky (01:55):

Excellent. So, tell us a little bit about yourself and your nursing journey and what drew you to hospice nursing.

Ashley Clifford (02:01):

Yeah. So, I have been a nurse for 8 years.

Carol Pehotsky (02:04):

Uh-huh.

Ashley Clifford (02:04):

I started off at Cleveland Clinic down in Surgical ICU here.

Carol Pehotsky (02:07):

Okay.

Ashley Clifford (02:07):

And I always found it to be so intimidating. I would walk into work a bucket of anxiety-

Carol Pehotsky (02:12):

Oh my gosh. (laughs)

Ashley Clifford (02:12):

... And leave in tears-

Carol Pehotsky (02:12):

Oh no.

Ashley Clifford (02:14):

... Because I was like, "Oh my goodness, that was the worst thing I've ever done." Like, it was just always so scary.

Carol Pehotsky (02:17):

Intense. Yeah.

Ashley Clifford (02:19):

But I always wanted to help people. And so, I was in Texas for a funeral and my aunt was on hospice care and I met her hospice nurse, and I was like, "You know what? I'm going to do that."

Carol Pehotsky (02:29):

Oh, wow.

Ashley Clifford (02:29):

And so, while my husband and I were sitting in the hotel room, I got onto Workday-

Carol Pehotsky (02:33):

Oh.

Ashley Clifford (02:33):

... Applied for a Cleveland Clinic hospice job and got the job.

Carol Pehotsky (02:37):

And here you are.

Ashley Clifford (02:37):

And here I am, and I wouldn't change it for the world.

Carol Pehotsky (02:39):

Wow. So, obviously a very meaningful experience for you. So, what have you drawn from that? Or what keeps you coming back for more?

Ashley Clifford (02:48):

I think the ability to help people.

Carol Pehotsky (02:48):

Mm-hmm.

Ashley Clifford (02:50):

I think that when I was in the ICU, which was the most wonderful learning experience for me-

Carol Pehotsky (02:56):

Sure.

Ashley Clifford (02:56):

... I knew it wasn't my calling.

Carol Pehotsky (02:58):

Mm. Mm-hmm.

Ashley Clifford (02:58):

I knew that I was not built for that, but that I know that somehow, some way, I had to make a difference in people's lives. And I've always been drawn to families.

Carol Pehotsky (03:05):

Oh, okay.

Ashley Clifford (03:05):

And I love the ability to walk into the home and make-

Carol Pehotsky (03:08):

Mm.

Ashley Clifford (03:08):

... Everyone feel comfortable-

Carol Pehotsky (03:09):

Mm-hmm.

Ashley Clifford (03:10):

... and everybody feels educated and give them the resources to make their loved ones feel that way as well.

Carol Pehotsky (03:16):

Wow. That's fantastic. So, your role is really unique compared to maybe what some of us have experienced as nurse in the ambulatory center or in hospitals, et cetera. So, what sort of things did you have to learn to sort of transition from that hospital-based ICU nurse into being able to be comfortable going to people's homes and- and the care you provide as a hospice nurse?

Ashley Clifford (03:36):

Yeah, absolutely, it was a huge transition.

Carol Pehotsky (03:38):

(laughs)

Ashley Clifford (03:38):

I think that all of us nurses are in such a mindset that we have to save everyone-

Carol Pehotsky (03:39):

Right.

Ashley Clifford (03:44):

... We have to fix everyone, we have to just keep moving forward and then there's step one, step two, step three. Whereas with hospice you kind of just take a step back and say, "You know what? I don't have to save you, but I can help you."

Carol Pehotsky (03:55):

Mm. Oh, yeah.

Ashley Clifford (03:56):

And so, you get to walk into these patients' homes and just help.

Carol Pehotsky (04:01):

Mm.

Ashley Clifford (04:01):

And so that was a whole different mindset for me was that-

Carol Pehotsky (04:01):

Yeah.

Ashley Clifford (04:04):

... I didn't have to keep doing, doing, doing, I just had to help them. And all these people want to do is be comfortable-

Carol Pehotsky (04:04):

Yeah.

Ashley Clifford (04:10):

... And be at home.

Carol Pehotsky (04:11):

Wow, that's fantastic. So, as I mentioned at the top of the episode, I know a little, just the tiniest bit about hospice nursing, being in a home or in a facility, but that was 20 years ago, so where can we find hospice nursing now?

Ashley Clifford (04:25):

Sure. You can find hospice nursing everywhere.

Carol Pehotsky (04:27):

Yeah.

Ashley Clifford (04:27):

It's here at main campus in all of these different buildings, it's in facilities in your neighborhood, it's in your neighbor's home that you would never guess.

Carol Pehotsky (04:37):

Sure.

Ashley Clifford (04:37):

Because patients are just at home. They're comfortable. Yeah.

Carol Pehotsky (04:41):

So, it's- it's about the care provided, not the location necessarily.

Ashley Clifford (04:44):

Correct, yeah. Hospice can be provided in any different situation.

Carol Pehotsky (04:47):

And what would lead a patient to, you know, there are hospice centers where patients are going to.

Ashley Clifford (04:48):

Yeah.

Carol Pehotsky (04:53):

What would be the circumstances where a patient would maybe transition from home hospice to one of those facilities?

Ashley Clifford (04:58):

Yeah. So, with hospice there's different levels of care.

Carol Pehotsky (05:01):

Okay.

Ashley Clifford (05:01):

And so, one of the levels of care is routine, and that's where we come into the home, we do all of our assessments, we educate family, and family is required to... They, you know, then care for their loved ones with the education that's been provided to them.

(05:14):

There's a respite level of care which can get them into a facility.

Carol Pehotsky (05:17):

Okay.

Ashley Clifford (05:17):

And that's saying that the family is sick, and they can't provide for that loved one-

Carol Pehotsky (05:20):

Oh, sure.

Ashley Clifford (05:20):

... And they just need a break.

Carol Pehotsky (05:22):

Yeah.

Ashley Clifford (05:22):

So, they get a few days where the patient goes into the care center-

Carol Pehotsky (05:25):

Mm-hmm.

Ashley Clifford (05:25):

... And then they come back home.

Carol Pehotsky (05:25):

Oh.

Ashley Clifford (05:27):

And then the last level to get into one of those facilities is a GIP, and that's saying that, you know, we've been in the house numerous times that week trying to control whether it's pain-

Carol Pehotsky (05:36):

Mm.

Ashley Clifford (05:36):

... Or nausea/vomiting, or agitation, some symptom that we're not able to manage well from home.

Carol Pehotsky (05:36):

Oh, okay.

Ashley Clifford (05:43):

So, we take them into the facility, we get that symptom under control-

Carol Pehotsky (05:46):

Mm-hmm.

Ashley Clifford (05:46):

... And then the plan is to send them back home.

Carol Pehotsky (05:48):

Okay.

Ashley Clifford (05:48):

Yeah.

Carol Pehotsky (05:48):

All right. Fascinating. So, a lot of your roles are probably in spaces where a lot of us would feel awkward.

Ashley Clifford (05:56):

Sure.

Carol Pehotsky (05:56):

So how have you learned, and how do you now train new hospice nurses how to have some of those difficult conversations, end of life conversations?

Ashley Clifford (06:04):

Yeah.

Carol Pehotsky (06:05):

And why.

Ashley Clifford (06:06):

I always just tell them to live in the awkwardness.

Carol Pehotsky (06:09):

(laughs)

Ashley Clifford (06:09):

I know that sounds crazy.

Carol Pehotsky (06:09):

Lean in. (laughs)

Ashley Clifford (06:10):

But just embrace it.

Carol Pehotsky (06:11):

Okay.

Ashley Clifford (06:12):

Having those difficult conversations is probably the easiest part of the job for me.

Carol Pehotsky (06:17):

Really?

Ashley Clifford (06:18):

It is, yes. Because it's a time that you really truly get to know who these people are.

Carol Pehotsky (06:18):

Mm.

Ashley Clifford (06:23):

And where they've been and where they want to go.

Carol Pehotsky (06:26):

Sure.

Ashley Clifford (06:26):

And so those difficult conversations help us support them.

Carol Pehotsky (06:27):

Mm.

Ashley Clifford (06:29):

And it lets us know if they want to pass at home, if they want to pass in a facility, what their-

Carol Pehotsky (06:35):

Oh, okay.

Ashley Clifford (06:36):

... Background is, and who they were. And it just kind of opens that door to that. And I always am just open and honest with everybody.

Carol Pehotsky (06:44):

Sure.

Ashley Clifford (06:45):

I am an open book. I'm super blunt and I just tell them, you know, this is what is expected, this is where we're at, and this is where I see that we're going.

Carol Pehotsky (06:52):

Okay.

Ashley Clifford (06:52):

So, I always feel like honesty is your number one key for those conversations.

Carol Pehotsky (06:56):

So, I imagine you've run into situations though where perhaps the patient and their family members aren't on the same page.

Ashley Clifford (07:01):

All the time.

Carol Pehotsky (07:01):

Okay. (laughs) So talk us through what that looks like and how you mitigate those situations.

Ashley Clifford (07:05):

Yeah. I think that in those difficult situations it's always important to remember that we are there to advocate for the patient. So-

Carol Pehotsky (07:13):

Sure.

Ashley Clifford (07:14):

... When you're in a room full of people that, you know, 99% of the room wants one thing and that one percent is your patient that wants-

Carol Pehotsky (07:21):

Right.

Ashley Clifford (07:21):

... Something completely different, you need to get-

Carol Pehotsky (07:23):

That's what you're there for.

Ashley Clifford (07:24):

... In their corner.

Carol Pehotsky (07:24):

Yeah.

Ashley Clifford (07:24):

And you need to, you know, listen to them.

Carol Pehotsky (07:24):

Mm-hmm.

Ashley Clifford (07:27):

And help others understand what they want.

Carol Pehotsky (07:29):

So, loss is something that comes hand in hand with hospice nursing. So how do you manage that yourself and sort of work through... I mean, it has to bring up feelings for the hospice nurse.

Ashley Clifford (07:39):

Yeah. You know, a couple years ago my mom was diagnosed with Stage IV rectal cancer-

Carol Pehotsky (07:44):

Oh, gosh.

Ashley Clifford (07:44):

... And thankfully we still have her with us-

Carol Pehotsky (07:44):

Oh, wow.

Ashley Clifford (07:46):

... And we are doing just fine for right now.

Carol Pehotsky (07:49):

Mm-hmm.

Ashley Clifford (07:49):

But I always put myself in their situation when I walk in there and it's sometimes hard for me when I walk into a home of a 56-year-old woman.

Carol Pehotsky (07:57):

Sure.

Ashley Clifford (07:58):

Or a 56-year-old male, or somebody younger.

Carol Pehotsky (08:00):

Mm-hmm.

Ashley Clifford (08:00):

It's hard to take yourself out of that situation.

Carol Pehotsky (08:03):

Yeah.

Ashley Clifford (08:03):

But you also have to remember that you are the professional and you are there for a reason. So, you kind of have to wear your heart midway down your arm.

Carol Pehotsky (08:11):

(laughs) Not quite on your sleeve, yeah.

Ashley Clifford (08:13):

Correct.

Carol Pehotsky (08:13):

Okay.

Ashley Clifford (08:14):

I think that's really important to be able to set that boundary-

Carol Pehotsky (08:17):

Mm-hmm.

Ashley Clifford (08:17):

... Between personal and professional.

Carol Pehotsky (08:18):

Mm-hmm.

Ashley Clifford (08:21):

And sometimes it's really hard.

Carol Pehotsky (08:22):

Yeah, I'm sure. They're in their homes-

Ashley Clifford (08:24):

Really hard. Especially-

Carol Pehotsky (08:25):

... You're at their side.

Ashley Clifford (08:25):

Yeah.

Carol Pehotsky (08:25):

Yeah.

Ashley Clifford (08:26):

And when you're, like, in your own personal life you have something like that going on-

Carol Pehotsky (08:30):

Right.

Ashley Clifford (08:30):

... It's hard but I think that, again, ill wrap around to the fact that we get to help people and I think that that for me, it overcomes the-

Carol Pehotsky (08:30):

Mm.

Ashley Clifford (08:39):

... The sadness-

Carol Pehotsky (08:40):

Okay.

Ashley Clifford (08:40):

... is because I helped that person get to what their goal was.

Carol Pehotsky (08:43):

Yeah. How would you help a nurse new to hospice sort of get to that same place?

Ashley Clifford (08:49):

Yeah. I think that no matter how much you talk, I don't think that I can-

Carol Pehotsky (08:52):

Right.

Ashley Clifford (08:52):

... Tell you how to get there.

Carol Pehotsky (08:53):

Yeah.

Ashley Clifford (08:54):

I think it's through experience.

Carol Pehotsky (08:56):

Mm.

Ashley Clifford (08:56):

And I think that you just have to do it in order to obtain that experience to have those feelings. But I really truly think that I would have to tell somebody to just give it time-

Carol Pehotsky (09:06):

Mm, yeah.

Ashley Clifford (09:07):

... And to be patient and open and honest.

Carol Pehotsky (09:10):

So sometimes in- in the media and the literature, you hear the phrase, "Having a good death."

Ashley Clifford (09:14):

Yeah.

Carol Pehotsky (09:15):

So, what does that mean to you as a hospice nurse?

Ashley Clifford (09:17):

Absolutely. I think that, you know, as hospice nurses, that's our whole goal is for them to have a good death. And so, to me, when I think about a good death, I think about A death that is comfortable, so you are not in pain.

Carol Pehotsky (09:31):

Mm-hmm.

Ashley Clifford (09:31):

You're not gasping for air. You're not surrounded by a family that is overly sad, I feel like they are prepared.

Carol Pehotsky (09:39):

Mm. Oh, sure.

Ashley Clifford (09:40):

Allowed to be sad but they are prepared for it.

Carol Pehotsky (09:43):

Mm-hmm.

Ashley Clifford (09:43):

Because we have done our job to prepare them. I think to me that is a good death, just knowing that you're comfortable, you're medicated, your family has helped you get there.

Carol Pehotsky (09:43):

Mm-hmm.

Ashley Clifford (09:52):

And your family has given you the permission and told you that they're going to be okay.

Carol Pehotsky (09:55):

Yeah. So, what sorts of things can nur- So I'm thinking also of, you know, death and dying as part of nursing in other settings. So, what advice would you have for the nurse, maybe not working hospice, to help families deal with those situations and feel more prepared, like you just mentioned.

Ashley Clifford (09:56):

Yeah.

Carol Pehotsky (10:12):

Like, is there anything we can do in other settings?

Ashley Clifford (10:14):

Yeah. I think that, you know, educating ourselves on death and dying is key, because a lot of nurses, even before I was a hospice nurse, I didn't know much about death and dying.

Carol Pehotsky (10:24):

No. Yeah.

Ashley Clifford (10:24):

I had no idea. I think so educating ourselves and-

Carol Pehotsky (10:24):

Mm-hmm.

Ashley Clifford (10:26):

... You know, reading some evidence on it and some literature, and then getting out there and actually speaking to patients and letting them-

Carol Pehotsky (10:26):

Hm.

Ashley Clifford (10:34):

... Know, like the evidence, like, carrying on the information that you have obtained and just being there. Some people don't want you to say anything-

Carol Pehotsky (10:34):

Right.

Ashley Clifford (10:40):

... some people just want you to stand there and just be present with them.

Carol Pehotsky (10:43):

Sure. That's great advice.

Ashley Clifford (10:44):

Yeah.

Carol Pehotsky (10:45):

So, the phrase hospice and palliative care get mixed up an awful lot, I think. (laughs)

Ashley Clifford (10:49):

Yeah.

Carol Pehotsky (10:50):

So, I'm sure you hear that all the time.

Ashley Clifford (10:51):

Yeah.

Carol Pehotsky (10:51):

How do you respond to that or- or help us get educated about that, please.

Ashley Clifford (10:55):

I think that still to this day there's times where I walk into a home and I'm like, "Man, are they hospice appropriate or are they palliative care?"

Carol Pehotsky (10:55):

(laughs) For sure, yeah.

Ashley Clifford (11:02):

Like, what's the difference here?

Carol Pehotsky (11:03):

Right.

Ashley Clifford (11:03):

Because it is very confusing.

Carol Pehotsky (11:06):

Mm-hmm.

Ashley Clifford (11:06):

But I think that with... The main differences with hospice is we have stopped all care and our whole goal is strictly comfort.

Carol Pehotsky (11:12):

Mm, okay.

Ashley Clifford (11:13):

Whereas palliative, they can still look to get better, but with hospice, we are no longer seeking that aggressive treatment. We are just solely focused on being comfortable.

Carol Pehotsky (11:22):

And I... Vague memories of there sort of being a time-

Ashley Clifford (11:26):

Yeah.

Carol Pehotsky (11:26):

... Permit around hospice. What does that look like?

Ashley Clifford (11:28):

So, with hospice we have to say that they have six months of life or less to live.

Carol Pehotsky (11:33):

Mm, sure.

Ashley Clifford (11:33):

And people, of course-

Carol Pehotsky (11:33):

Right.

Ashley Clifford (11:35):

... Live longer than six months.

Carol Pehotsky (11:36):

(laughs) They're going to do what they're going to do, yeah.

Ashley Clifford (11:36):

Yeah, absolutely. We're not God, I don't know how long you're going to live.

Carol Pehotsky (11:39):

(laughs)

Ashley Clifford (11:39):

But your disease progress tells us-

Carol Pehotsky (11:42):

Mm.

Ashley Clifford (11:42):

... That you have less than six months-

Carol Pehotsky (11:42):

Sure.

Ashley Clifford (11:44):

... Of expectations.

Carol Pehotsky (11:46):

If somebody gets to month six and is still... What happens then? Can you renew hospice care?

Ashley Clifford (11:46):

Yeah.

Carol Pehotsky (11:51):

Can you continue?

Ashley Clifford (11:52):

Absolutely. So, we reevaluate all the time.

Carol Pehotsky (11:54):

Mm-hmm.

Ashley Clifford (11:55):

Um, it's the first couple certification periods are, you know, longer.

Carol Pehotsky (11:59):

Mm-hmm.

Ashley Clifford (11:59):

And then after that they are in touch with the doctor through FaceTime every nine weeks, we re-certify them and say, "Hey, you know what? I see a decline and you're still appropriate for hospice," or "I think you're doing good," and they can graduate and that's one of the best parts of that job-

Carol Pehotsky (12:00):

Sure.

Ashley Clifford (12:13):

... Is being able to graduate somebody-

Carol Pehotsky (12:14):

Yeah.

Ashley Clifford (12:15):

... From hospice. It's awesome.

Carol Pehotsky (12:16):

Yeah, absolutely. So, I'm sure you get to know your patients really well. How does that help you provide individualized care and then how does that affect you as a human being when their life does end?

Ashley Clifford (12:26):

Yeah. So, providing that individualized care is huge.

Carol Pehotsky (12:30):

Mm-hmm.

Ashley Clifford (12:30):

People are so different, and everybody's journey is, like, black and white.

Carol Pehotsky (12:35):

Right.

Ashley Clifford (12:35):

Nobody's journey is ever going to be the same. And so, I think that you have patients that don't want any relation with you. They want it to be-

Carol Pehotsky (12:42):

Oh, okay. Sure.

Ashley Clifford (12:43):

... Black and white.

Carol Pehotsky (12:43):

Business.

Ashley Clifford (12:44):

You're here to do a job.

Carol Pehotsky (12:45):

Yeah, yeah.

Ashley Clifford (12:45):

This is what it is.

Carol Pehotsky (12:45):

Mm-hmm.

Ashley Clifford (12:46):

And then you have these patients that you walk through the door, and they want you to hold their hand-

Carol Pehotsky (12:51):

Yeah.

Ashley Clifford (12:51):

... And they want you to tell them your whole life story because they want to be comfortable with you. And so, I think just reading the room is key.

Carol Pehotsky (12:51):

Mm-hmm.

Ashley Clifford (12:58):

And listening to them. They're going to guide you as to what they want.

Carol Pehotsky (13:02):

I can- I can only imagine, you know, I- I still remember patients who ended up being DNR-

Ashley Clifford (13:02):

Yeah.

Carol Pehotsky (13:07):

... Way back when I was taking care of patients. Those patients still stay with me.

Ashley Clifford (13:10):

Yup.

Carol Pehotsky (13:10):

And so, knowing that the line of work you do, how do you work through some of those good deaths but people you got really close to in the line of hospice nursing?

Ashley Clifford (13:19):

Yeah. Man, I've had a couple of those.

Carol Pehotsky (13:19):

Yeah.

Ashley Clifford (13:21):

And those are- those are hard.

Carol Pehotsky (13:21):

Yeah.

Ashley Clifford (13:22):

Those are ones where you're like, "Oh," I just... they, like, become like your family-

Carol Pehotsky (13:23):

Yeah.

Ashley Clifford (13:26):

... And your mindset., and they've been with you for a long time and-

Carol Pehotsky (13:26):

Mm-hmm.

Ashley Clifford (13:30):

... You know, you can see the progression but you're just never ready for it. Those ones hurt.

Carol Pehotsky (13:34):

Yeah.

Ashley Clifford (13:34):

They do. And you're allowed to feel those feelings and you're-

Carol Pehotsky (13:34):

Mm-hmm.

Ashley Clifford (13:37):

... Allowed to be sad., you know. Just letting people know I- I just need, like, an hour or so. I just need to... Your management team, letting them know that-

Carol Pehotsky (13:37):

Oh, sure.

Ashley Clifford (13:44):

... I need some time.

Carol Pehotsky (13:45):

Yeah.

Ashley Clifford (13:45):

I just need to-

Carol Pehotsky (13:46):

Mm-hmm.

Ashley Clifford (13:46):

... Grieve this for a little bit and then I will be okay. And so, allowing yourself to feel those feelings is huge I believe. I had a patient that passed away about a year ago and he was my best little buddy.

Carol Pehotsky (13:58):

Aw.

Ashley Clifford (13:58):

And I decided that I was going to attend his funeral-

Carol Pehotsky (13:58):

Okay.

Ashley Clifford (14:01):

... And I don't attend many funerals because I- I don't know why but I just don't.

Carol Pehotsky (14:05):

Okay.

Ashley Clifford (14:05):

But I decided I was going to attend his.

Carol Pehotsky (14:07):

Mm-hmm.

Ashley Clifford (14:07):

And to me it was a moment of closure. And with that closure-

Carol Pehotsky (14:07):

Sure.

Ashley Clifford (14:11):

... And seeing that his family was okay-

Carol Pehotsky (14:13):

Ah, okay.

Ashley Clifford (14:15):

... And all was right in the world.

Carol Pehotsky (14:16):

Mm-hmm.

Ashley Clifford (14:16):

He was in a better place; he was no longer suffering-

Carol Pehotsky (14:19):

Mm-hmm.

Ashley Clifford (14:19):

... and that, to me, brought me a sense of peace.

Carol Pehotsky (14:21):

Wow, yeah, well, I actually in my head formulated the question about going to patients' funerals.

Ashley Clifford (14:25):

Yeah.

Carol Pehotsky (14:26):

Any advice you have? Because sometimes... I remember- you know, I way back remember inpatient, like, patients passing away and patients' families saying, you know, asking people if they would come or you- you see the information. You're- you're judging whether it's appropriate to be there or not as their nurse.

Ashley Clifford (14:38):

Yeah. I used to question whether it's appropriate to be there all the time.

Carol Pehotsky (14:39):

Mm-hmm.

Ashley Clifford (14:42):

And now I think it's more of a personal thing. If I feel the need that I need to go-

Carol Pehotsky (14:42):

Mm-hmm.

Ashley Clifford (14:46):

... Then I go. There's a lot of times that we're mentioned in obituaries and you're like, "Oh."

Carol Pehotsky (14:50):

Wow.

Ashley Clifford (14:50):

And I feel guilty I didn't go to that one. But you can't let that guilt-

Carol Pehotsky (14:55):

Right.

Ashley Clifford (14:55):

... Ride you. You- you have to do what's best for you.

Carol Pehotsky (14:55):

Sure.

Ashley Clifford (14:58):

And there's funerals where I know that I need to go. I know that I need that closure.

Carol Pehotsky (14:59):

Mm-hmm.

Ashley Clifford (15:03):

And there's other ones that I feel like, you know, once we've been to the pronouncement, I've talked to the family, I'm at peace and I don't need to attend that.

Carol Pehotsky (15:09):

Okay.

Ashley Clifford (15:09):

So, I think it's on a personal basis and on a patient-to-patient basis.

Carol Pehotsky (15:13):

And as a way to take care of yourself.

Ashley Clifford (15:14):

Absolutely. Yeah.

Carol Pehotsky (15:15):

[inaudible 00:15:15]

Ashley Clifford (15:15):

It's a lot of self-help.

Carol Pehotsky (15:16):

Yeah, for sure.

Ashley Clifford (15:17):

Yup.

Carol Pehotsky (15:17):

So, what does a typical day look like in the life of a hospice nurse?

Ashley Clifford (15:20):

Yeah. So, I work four 10s.

Carol Pehotsky (15:22):

Okay.

Ashley Clifford (15:23):

I am off every Wednesday.

Carol Pehotsky (15:25):

(laughs) Yeah, oh sure.

Ashley Clifford (15:25):

It's a great midweek break.

Carol Pehotsky (15:25):

Yeah.

Ashley Clifford (15:25):

It's phenomenal.

Carol Pehotsky (15:25):

(laughs)

Ashley Clifford (15:27):

So, I start at 7:00 AM and so typically from 7:00 to 8:00 I'm kind of gathering all my information from my patients, doing some emails, research, gathering my day and kind of organizing it. And then I would say from 9:00 to, like, 4:00-is, 4:00, 5:00, depends on the day-

Carol Pehotsky (15:43):

Mm-hmm. (laughs)

Ashley Clifford (15:44):

... Um, and the needs of all those patients out there-

Carol Pehotsky (15:46):

Sure.

Ashley Clifford (15:46):

I'm out in the field.

Carol Pehotsky (15:48):

Okay.

Ashley Clifford (15:48):

And I'm typically going out and seeing my routine patients that I see every week.

Carol Pehotsky (15:51):

Mm-hmm.

Ashley Clifford (15:51):

And assessing them and making sure they have all of their supplies, all their equipment-

Carol Pehotsky (15:55):

Mm-hmm.

Ashley Clifford (15:56):

Making sure that they're not in need of any other medications for symptom management. And so, I typically do that all day and then I wrap my day up at home by, you know, finishing my charting-

Carol Pehotsky (16:06):

Mm-hmm.

Ashley Clifford (16:06):

... And whatnot.

Carol Pehotsky (16:07):

Yeah.

Ashley Clifford (16:08):

And then, you know, triage is always in need of something so we're always out there-

Carol Pehotsky (16:11):

Okay.

Ashley Clifford (16:11):

... Helping with symptom management visits for patients-

Carol Pehotsky (16:12):

Oh, okay.

Ashley Clifford (16:13):

... That call in and say, you know, they're having so and so go on and we always try to help fill in the gap with the rest of the field staff.

Carol Pehotsky (16:20):

So, it's... There's- there's sort of the patients you're managing their care and then on top of there could be sort of urgent calls where you need-

Ashley Clifford (16:28):

Yeah, absolutely, yeah.

Carol Pehotsky (16:28):

All right.

Ashley Clifford (16:29):

All day long.

Carol Pehotsky (16:30):

Wow. So, I, you know, I'm thinking about, as a nurse in the hospital you pick up the phone, you call the doctor, boom, you get an order. What does that look like for you? You're- you're going about your day, and you can definitely tell somebody needs a different medication order or maybe they do need to go into that respite center. So, what does that look like in terms of getting more help?

Ashley Clifford (16:46):

Sure. You know, I will say that Cleveland Clinic Hospice has the best team-

Carol Pehotsky (16:47):

Mm-hmm.

Ashley Clifford (16:51):

... Of people I have ever worked with, right from our management, right down to the home health aides. And so, if I need more help from a doctor-

Carol Pehotsky (17:00):

Mm-hmm.

Ashley Clifford (17:00):

... As far as orders for a symptom management visit, or if I need to send them into the care center, it is a quick message away and it is a response within 15, 20 minutes.

Carol Pehotsky (17:10):

Oh, wow.

Ashley Clifford (17:10):

It is phenomenal. Our doctors are wonderful, that's on our team. And, you know, sometimes it's not the doctors that you need. Sometimes it's just I need help cleaning this patient.

Carol Pehotsky (17:19):

Yeah. Another set of hands, yeah.

Ashley Clifford (17:20):

Yeah, an extra set of hands. I'm not an octopus.

Carol Pehotsky (17:23):

(laughs)

Ashley Clifford (17:23):

And so, we have home health aides that are always right around the corner and they're like, "Hey, you know, I'll come help you."

Carol Pehotsky (17:23):

All right.

Ashley Clifford (17:28):

And so, you're alone-

Carol Pehotsky (17:29):

Mm-hmm.

Ashley Clifford (17:29):

... You're never alone.

Carol Pehotsky (17:30):

Okay.

Ashley Clifford (17:31):

Yeah.

Carol Pehotsky (17:31):

All right.

Ashley Clifford (17:31):

It's wonderful.

Carol Pehotsky (17:32):

So now thinking about our nurses who have been maybe in ambulatory care, maybe in home care, or in the hospital and- and they've also been intrigued by what you have to say, so what advice would you have for them about sort of that transition into this type of nursing, or what homework they need to do to determine if it's really right for them?

Ashley Clifford (17:51):

Yeah. When I applied for the position, I knew that I had wanted to leave my previous job.

Carol Pehotsky (17:51):

Mm-hmm.

Ashley Clifford (17:57):

But I wasn't sure that it was going to be fulfilling.

Carol Pehotsky (17:59):

Mm.

Ashley Clifford (17:59):

I was like, man, maybe it's going to be boring. What do I do? How am I going to do this?

Carol Pehotsky (18:03):

Sure.

Ashley Clifford (18:04):

It's fast paced. Things are always changing-

Carol Pehotsky (18:06):

Hm.

Ashley Clifford (18:06):

... Your caseload is always changing. You are never bored. There's always somebody out there that needs something. So, I would say that be ready to hit the ground with your feet running. Like-

Carol Pehotsky (18:16):

Mm-hmm.

Ashley Clifford (18:17):

... You're going to be busy. And it... But it's so much fun and it's so rewarding.

Carol Pehotsky (18:20):

Wow. So, you've been in hospice long enough that you were in hospice care pre-pandemic, during the pandemic, and now. So, what sort of evolution have you seen? Is there anything good that came out of it that we've still been able to maintain for our patients? What- what has that journey been like for you as a hospice nurse?

Ashley Clifford (18:38):

I would say that now that the pandemic is over, we're not starting to be welcomed into patients' homes. We're not saying-

Carol Pehotsky (18:38):

Oh, sure.

Ashley Clifford (18:45):

... that we weren't so much welcomed, but it was more that-

Carol Pehotsky (18:45):

Yeah.

Ashley Clifford (18:48):

... People were on edge.

Carol Pehotsky (18:49):

Mm-hmm.

Ashley Clifford (18:49):

Because they don't know where we came from-

Carol Pehotsky (18:49):

Sure.

Ashley Clifford (18:51):

... They don't know what our health history is.

Carol Pehotsky (18:51):

Mm-hmm.

Ashley Clifford (18:53):

And so now people are, again, open arms and doctors are starting to come into patients' homes again.

Carol Pehotsky (18:59):

Mm-hmm, mm-hmm.

Ashley Clifford (18:59):

And so, it's not so edgy.

Carol Pehotsky (19:02):

Okay.

Ashley Clifford (19:02):

Like, nobody's overly concerned-

Carol Pehotsky (19:04):

Yeah.

Ashley Clifford (19:04):

... at this point. You still have your patients where you walk in their home and they're like, "Hey, can you grab a mask?"

Carol Pehotsky (19:08):

Of course.

Ashley Clifford (19:08):

"Can you do this?"

Carol Pehotsky (19:08):

Mm-hmm.

Ashley Clifford (19:09):

And absolutely, by all means. But for the most part I think that people are now starting to settle back down into normal life.

Carol Pehotsky (19:15):

Okay. Good.

Ashley Clifford (19:16):

Yeah.

Carol Pehotsky (19:16):

Glad to hear it.

Ashley Clifford (19:17):

I love it.

Carol Pehotsky (19:17):

(laughs) So I can keep talking to you for ages, but wrapping up this topic, what are some of the most important things you've learned from your patients?

Ashley Clifford (19:25):

Yeah. Patience.

Carol Pehotsky (19:27):

Mm-hmm.

Ashley Clifford (19:27):

I have learned how to be patient because that is a huge, huge thing for me. I'm very type A.

Carol Pehotsky (19:28):

(laughs)

Ashley Clifford (19:34):

So, learning how to be patient and learning how to open my ears and listen before I react.

Carol Pehotsky (19:40):

Mm.

Ashley Clifford (19:40):

Because I think that all of us as individuals and nurses that we just listen to react-

Carol Pehotsky (19:45):

Mm-hmm. (laughs)

Ashley Clifford (19:46):

... Instead of just listen to really truly understand. And these patients have really taught me the importance of listening to understand. Because if we don't fully understand, we can't take care of them appropriately.

Carol Pehotsky (19:58):

That's right.

Ashley Clifford (19:58):

Yeah.

Carol Pehotsky (19:58):

Well, that's fantastic advice. Thank you.

Ashley Clifford (19:58):

Yeah.

Carol Pehotsky (20:00):

So now we're going to flip to our speed round where we get to know you a little bit more as a human being and not just the amazing nurse that you are. So first we'll start with, so it's time to unwind, you've had a tough day, what do you do to take care of you?

Ashley Clifford (20:12):

I have four kiddos.

Carol Pehotsky (20:13):

Oh. (laughs)

Ashley Clifford (20:13):

So, we are constantly at a baseball field.

Carol Pehotsky (20:15):

(laughs) Yeah, yes.

Ashley Clifford (20:17):

I really truly, my time to unwind is watching them play.

Carol Pehotsky (20:20):

That's wonderful.

Ashley Clifford (20:21):

Yes, it is.

Carol Pehotsky (20:22):

Yeah. Wow.

Ashley Clifford (20:22):

And I have a group of four best friends that we are always together.

Carol Pehotsky (20:26):

Oh, good.

Ashley Clifford (20:26):

And so that's my time to unwind.

Carol Pehotsky (20:28):

Thanks. Awesome.

Ashley Clifford (20:29):

It's with my people.

Carol Pehotsky (20:29):

Yeah. So, audience, I'll let you in on a little inside story. So, as we were preparing for this episode, I had asked Ashley if she wasn't a nurse what would her passion career be, and can you share with them what you told me before we started recording?

Ashley Clifford (20:41):

Yeah. I have no idea.

Carol Pehotsky (20:41):

(laughs)

Ashley Clifford (20:42):

I feel like every little girl dreams of being a teacher or something. I know when I was about four, I wanted to be a garbage man.

Carol Pehotsky (20:49):

(laughs)

Ashley Clifford (20:49):

But that's all I can really think of.

Carol Pehotsky (20:50):

Yeah.

Ashley Clifford (20:51):

My whole life I've known I was going to be a nurse.

Carol Pehotsky (20:53):

There you go.

Ashley Clifford (20:53):

My grandma is a Type I diabetic so from the time I was probably four or five I can remember helping her do her injections.

Carol Pehotsky (21:00):

Aww.

Ashley Clifford (21:00):

And I just knew that's where I was going.

Carol Pehotsky (21:02):

There you go.

Ashley Clifford (21:02):

Garbage man wasn't going to cut it so here I am.

Carol Pehotsky (21:06):

(laughs) All right. Well thank you so much for joining me today.

Ashley Clifford (21:08):

Yeah, thank you for having me, it's been a pleasure.

Carol Pehotsky (21:14):

As always, thanks so much for joining us for today's discussion. Don't miss out, subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org.

(21:34):

To learn more about nursing at Cleveland Clinic, please check us out at Clevelandclinic.org/nursing.

(21:40):

Until next time, take care of yourselves and take care of each other.

(21:48):

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.