278 Grief and Loss Across the Lifespan
with a younger population, and the most curious of responses came from a
few social workers who talked about the pace of the work.
This idea of pace was intriguing but not completely surprising. The pace
of the work has changed since I began working in hospice some 11 years ago
at a small independent hospice. Now, my practice is with a large metropolitan
academic health system. On average, the hospice census is about 170 patients
(comprised of patients receiving care in their homes or in our general inpatient
unit—a small number of patients reside in nursing home settings). Each social
worker manages a case load of 25 to 30 patients.
The hospice serves a younger demographic (average age range
40–60 years), with 85% of the referrals emanating from the health system’s
hospitals and physician practices. Patients seek care within the health system,
sometimes as a last resort, because of the reputation for advanced and cutting
edge treatments, particularly in the area of cancer. The health system has a
palliative care program which supports patients undergoing challenging treat-
ments, and the hospice also supports those patients with a palliative home
care program. Palliative care programs continue to expand, and while patients
have benefited from this focus on the palliation of symptoms—it may be a
contributing factor in the ever decreasing length of stay for hospice patients.
Currently, the average length of stay at the hospice is 10 to 45 days; the main
contributor to that statistic is the increasing number of patients who are pro-
vided hospice care in the final days of life. The shorter length of stay coupled
with the tremendous turnover of patients (60%–70% of patients on service die
each month), is the “pace” the social workers are talking about. The “pace” as
they put it, has altered the practice of hospice social work.
Hospice work is relational work (Reupert, 2007). Social workers are
charged with not only educating families about hospice services and benefits,
but more importantly, at the heart of the practice is helping patients and fami-
lies negotiate the challenges at the end of life. The challenges include the phys-
ical symptoms, body changes, loss of control and independence, increased
lethargy, and the existential emotional challenges of saying good bye. Essential
to the work is the use of self, staying present, and bearing witness to pain-
ful experiences. The work requires knowledge and skill, but because of the
emotions aroused in working with the dying, it is essential for social workers
to have good coping skills and personal emotional resources to manage the
exposure to the dying process (Berzoff, 2008; Kanter, 2007). Rando (1984) talks
about how “being present” with dying requires the clinician to tolerate their
own death anxiety, while simultaneously providing a holding environment for
the anxieties of individuals in their care. When workers are exposed to a high
volume of death and suffering, they risk of losing their sense of professional
identity and compassion. The work can begin to lose meaning, a risk identi-
fied both in the literature (Berzoff & Kita, 2010; Seno, 2010) and by the social
workers with whom I work. End of life work is highly personal, and with
increased rapid exposure to death scenes—the losses may become personal
too. The decreasing opportunity to engage in relational work is yet another
loss for the clinician. The grief begins to stack up.
As the practice leader of the hospice psychosocial staff, this cumulative
experience of loss is a focus of my work. Often I see that the staff does not feel
entitled to their feelings of loss, an unrealistic expectation of their professional