Occupational therapists have a unique position and skill set when working with clients in the hospice setting.  Because the OT profession focuses on improving quality of life for all clients, even with the end of life component of hospice work and its associated stressors, working in a setting where the focus is more fully on the clients’ wishes and needs and much less on bureaucratic technicalities can be surprisingly positive and fulfilling.  But working in the hospice setting also poses its own unique challenges.  Here are three considerations that can help you to be successful as a hospice OT.

Help the client to set realistic goals
Even if a client in hospice has not yet come to grips with their approaching death, they are likely very much aware of what they have lost and are continuing to lose.  As a result, they may have unrealistic goals for what they would like to achieve during therapy services.  While this does not mean that the occupational therapist needs to tell the client that their goals are unrealistic and unachievable, the occupational therapist can help shift the focus from the “long term” and likely never-to-be-met goals to more short-term achievable goals.  In this way, the client will be better able to see progress and maintain motivation in working towards their goals.  

For example, I have had clients who have been bed bound for months and suddenly wished to get out of bed and into a chair.  Medically, this was impossible and could literally kill them, but it was their goal.  Rather than breaking the news to them that they would most likely never get out of bed again, I would instead explain the difficulty of immediately attempting this “long term goal” and suggest that we instead start by elevating the head of the bed a little bit at a time and working to increase their tolerance more and more each day.  Even if these clients never achieved the goal of getting out of bed, just being able to work towards that goal in a tolerable manner made all the difference to them.

Present immediate solutions
Clients in the hospice setting do not have long to live and quite honestly might not be alive next week—or even tomorrow—to enjoy your perfect solution to their problem.  So while this doesn’t mean you can’t still work on making that perfect solution happen, you also shouldn’t make your client wait if there is another good, if not quite as perfect, solution available now. 

For example, many times I have received consults for clients who needed occupational therapy services to improve their positioning and increase their comfort when out of bed in a chair or wheelchair.  I didn’t always have the best cushions or positioning devices available just sitting in my supply closet, but I quickly learned how to improvise and come up with a solution that got the client out of bed and tolerably comfortable in their chair so that they could be up today rather than lying in bed until tomorrow.  Often they would only enjoy this newfound freedom for a few days at most before declining further and being unable to tolerate out of bed activity, but just those few days made all the difference to the clients and their families.

Use your mental health skills
Occupational therapy has a strong tradition in mental health.  When working with clients and families who are facing the stressful and sometimes overwhelming aspects of end of life decisions, this mental health tradition and experience can be an invaluable resource for occupational therapists.  By knowing what mental health stressors our clients and their families may experience, we can be better prepared to truly listen to what they are saying to us—both verbally and non-verbally—and meet even their unspoken needs.  

Sometimes, just the process of occupational therapy itself and the ability to set and work towards goals can make a world of difference to someone’s mood and overall mental health.  I have had multiple clients who got more enjoyment in the last days of their lives out of being able to work towards occupational therapy goals, even if they never actually achieved those goals before they died.  

Working in hospice can be difficult as we say goodbye to patients again and again, but it can also be very meaningful and fulfilling.  In a lot of ways, hospice is one of the settings where we can be the truest to our profession as OTs.  Because it is in the hospice setting, when we are faced with the inevitability of death, that we can forget about all of the distractions faced throughout our lives and instead help our patients to focus on the process of truly living, for that is what makes life meaningful.