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Careers in hospice care

Kathleen Green | August 2015

A hospice nurse in Billings, Montana, was caring for a cancer patient who began gaining weight. The nurse, concerned that the patient’s cancer was spreading, suggested an ultrasound. But the scan showed no change in her condition.

Ultimately, the nurse and the rest of the hospice team concluded that the patient’s weight gain was an indirect result of her enrollment in hospice. “She was going out more, eating meals with her family, going to movies,” says Roxanne Allen, supervisor of the patient’s hospice provider. “She was gaining weight because she was off chemo and enjoying a better quality of life.”

Helping terminally ill patients and their families enjoy quality of life is a goal of hospice workers. Hospice teams include nurses, therapists, coordinators, and others who work together to minimize a patient’s anxiety and discomfort in preparing for death. “People don’t realize all the things we do for patients,” says Allen. “We manage their symptoms so they have quality time with family and friends to accomplish goals or tasks in the time they have left.”

Keep reading to learn more about some of the occupations in hospice care that the U.S. Bureau of Labor Statistics (BLS) projects to have employment growth between 2012 and 2022. This article provides an overview of hospice care, brief occupational descriptions, a glimpse of the rewards and challenges of the work, and information about preparing for a hospice career.

Overview of hospice care

Hospice is a healthcare option for people of all ages who have a medical prognosis of 6 months or less to live due to a terminal illness, such as late-stage cancer, or a life-limiting injury, such as trauma from an accident. In addition to treating patients medically, the hospice team provides emotional, psychological, and spiritual support to patients and their families.

The number of people seeking hospice services continues to rise. But many people delay enrollment until their final days. This section explains the process of enrolling in and receiving hospice care.

Enrollment

People who meet hospice criteria may enroll in a program of their choice. Prospective patients or their family members find and contact a hospice provider, and a representative of that provider arranges for a meeting with someone from the hospice team.

A team member, such as a social worker, often makes a home visit to explain the hospice philosophy and to answer questions. The team member may enroll the patient at home, and a hospice physician certifies eligibility to complete the process. Other members of the hospice team, such as a registered nurse and a volunteer coordinator, visit to assess the patient’s and family’s needs and to prepare a treatment plan.

 

Hospice enrollment is voluntary and flexible, and, if the hospice physician confirms that a patient’s prognosis is 6 months or less, the patient may enroll. Patients who outlive their prognosis may be recertified for as long as they continue to meet program requirements. “If a disease runs its normal course, it’s 2 or 3 or 6 months,” says hospice volunteer coordinator Ilene Kotajarvi of Escanaba, Michigan. “But you never know. We’ve had people who’ve lived for a couple of years.”

Support and treatment

A large component of hospice treatment is palliative care, which focuses on relief from pain and other symptoms of serious illness. But the hospice team also addresses a patient’s nonmedical needs, such as managing the stress of end-of-life decisionmaking. Hospice workers also help family members cope with their loved one’s dying and death.  

Although there are inpatient facilities, hospice providers most often offer home care; some have both facilities and home care. The number and duration of visits from hospice team members, whether at home or in a facility, may increase or decrease as the patient’s condition changes.

Family members’ involvement is encouraged at all stages of hospice care. Unless a patient is incapacitated, however, the family does not make decisions about treatment. “As long as the person is alert and oriented, we respect the dignity of our patient,” says Chuck Wilcox, a hospice social worker in Peoria, Illinois. “We ask the patient, ‘What do you want to do?’ During a difficult time, this gives the person a sense of choice.”

Increasing awareness

Enrollment in hospice programs has risen steadily over the past two decades. According to the National Hospice and Palliative Care Organization, the number of people who received hospice services between 1990 and 2013 increased more than 7 times, from 210,000 to over 1.5 million. The number of hospice providers more than tripled during that same period, from 1,600 to 5,800.

BLS counts hospice providers as part of the health care and social assistance sector. Of all industry sectors BLS studies, this industry is projected to have the fastest employment growth and to add the largest number of jobs between 2012 and 2022. And several occupations employed by hospice providers are projected to add many jobs, grow quickly, and have many job openings. (See table 1.)

Table 1. Employment growth and job openings for selected hospice occupations, projected 2012–22

Occupation	Employment		Employment change, projected 2012-22
	2012	Projected 2022	Number	Percent(1)	Job openings due to growth and replacements(2)
Personal care aides	1,190,600	1,771,400	580,800	49	666,000
Home health aides	875,100	1,299,300	424,200	49	590,700
Medical secretaries	525,600	714,900	189,200	36	252,500
Physical therapists	204,200	277,700	73,500	36	123,700
Occupational therapists	113,200	146,100	32,800	29	48,200
Healthcare social workers	146,200	185,500	39,200	27	70,200
Licensed practical and licensed vocational nurses	738,400	921,300	182,900	25	363,100
Medical and health services managers	315,500	388,800	73,300	23	149,900
Nursing assistants	1,479,800	1,792,000	312,200	21	593,600
Registered nurses	2,711,500	3,238,400	526,800	19	1,052,600
Footnotes: (1) For all occupations in the economy, employment change is projected to be 11 percent between 2012 and 2022. (2) Data show job openings projected to arise from both employment growth and the need to replace workers who leave the occupation permanently.
Source: U.S. Bureau of Labor Statistics, Employment Projections program.

Hospice is often considered a last resort, and many patients enroll in what turns out to be their final days. For example, studies show that most patients spend less than a month—about 23 days, on average, in 2012—in hospice, and enrollment often follows a hospital stay in intensive care.

Hospice advocates emphasize to physicians the importance of having difficult end-of-life conversations with their patients sooner, rather than later, to inform eligible patients and their families about the hospice option. “We want to provide quality of life,” says Rachael Latta, a registered nurse for a hospice in Escanaba, Michigan. “Our job is to ease the dying process for patients and help their families get through it.”

Occupations in hospice care

Hospice teams may include both volunteers and paid workers who address the different needs of patients and their families. Organizational structure varies by hospice provider, but the occupations described in this section are common in many hospices. Large hospices may have several positions for these occupations; small hospices may hire part-time workers or consultants for some occupations, such as medical director.

Healthcare occupations

Healthcare practitioner and technical occupations and healthcare support occupations make up the largest group of hospice caregivers. These workers are responsible for medical and palliative treatment, but they also provide emotional support.

Dietitians. Hospice dietitians assist patients in meeting their nutritional needs and educate patients and their families about changes that occur during the course of illness, such as when the patient’s body no longer absorbs nutrients.

Hospice aides. Also called home health aides, hospice aides help patients with medical or personal tasks. These tasks include bathing, grooming, and completing small chores; assisting with basic movement; and, in some states, administering prescribed medications.

Medical directors. Also called hospice physicians, these workers review enrollments for certification or recertification, collaborate with the hospice team to develop patient care plans, and act as the primary physician for patients who don’t already have one.

Nurses and assistants. Different types of nursing workers may be part of the hospice team. Registered nurses serve as case managers and patient advocates; they monitor patients, record observations and changes, and administer medication and treatment. Licensed practical and licensed vocational nurses assist registered nurses in monitoring patients, dispensing basic treatment, and maintaining records.

Nursing assistants help patients with tasks such as eating and bathing; measure and record vital signs, such as blood pressure; and aid patients and their families in the use of medical equipment.

Because of their advanced training, nurse practitioners may serve as the liaison between doctors and nurses. In addition, they often are responsible for completing in-person visits with patients who are still in hospice after 6 months and for providing recommendations to the medical director about whether to continue hospice services.

Therapists. These workers provide different types of therapy to relieve patients’ pain and make them feel comfortable. For example, occupational therapists help patients engage in everyday activities, and physical therapists assist with mobility and strength.

Other. Other healthcare-related hospice occupations include massage therapists, music therapists, and pharmacists.

Community, personal, and social service occupations

Workers in community and social service occupations and personal care and service occupations focus on the patient’s or family’s emotional and spiritual needs.

Counselors. These workers provide spiritual and emotional support to patients and offer bereavement support to family members for up to 1 year after a hospice patient dies. Hospice counselors also may lead seminars, support groups, and workshops on grieving.

Personal care aides. Personal care aides help hospice patients with everyday tasks, such as shopping and light housekeeping; assist with personal hygiene; and provide companionship. 

Social workers. Healthcare social workers help hospice patients with nonmedical needs, educate family members on caregiving and other topics, and guide patients and their families in discussing their concerns.

Other. Other community, personal, and social service occupations employed by hospice providers include clergy, social and human service assistants, and recreation workers.

Management, business, and administrative occupations

Hospice providers need workers in management, business and financial operations, and administrative support occupations to ensure that their organization offers reliable, cost-effective services and complies with government regulations.

CEO or manager. The chief executive officer (CEO) or manager oversees hospice operations by supervising staff; establishing and directing the organization’s goals; reviewing documents, including policies and procedures, contracts related to the organization, and paperwork involving patients; and ensuring compliance with federal and state regulations.

 

CFO or finance officer. Also called financial managers, these workers develop and oversee the hospice budget; billing for Medicare, Medicaid, and private insurance; and charitable giving to the hospice.

Medical secretaries. Medical secretaries compile patients’ health records and prepare reports to submit for regulatory purposes, such as to show compliance with laws regarding staffing. They also may process insurance payments.

Receptionists. The hospice receptionist greets visitors and answers the phone to direct callers to the proper staff member. A receptionist also listens to and supports patients and their families.

Volunteer coordinators. These workers are human resources specialists who screen, train, and supervise hospice volunteers. They also evaluate each patient’s needs to match him or her with volunteers, such as videographers or photographers who record patients’ stories or activities for family keepsakes.

Other. Other management, business, and administrative occupations employed by hospice providers include bookkeeping, accounting, and auditing clerks; customer service representatives; and human resources managers.

Rewards and challenges of hospice work

Knowing that patients are nearly certain to die in your care may be a difficult part of hospice work. But these workers say they are drawn to helping others, and that provides job satisfaction.    

Rewards

The median annual wage for most of the hospice occupations in table 2 was higher than the $35,540 median wage for all occupations in May 2014, according to BLS. But few hospice workers enter these careers for the earnings potential.  

Table 2. Employment and wages for selected occupations in industries providing hospice services, May 2014

Occupation	Home health care services		Skilled nursing facilities
	Employment	Median annual wage	Employment	Median annual wage
Healthcare
Dietitians and nutritionists	1,180	$63,340	4,950	$57,760
Home health aides	348,740	21,160	27,470	21,670
Licensed practical and licensed vocational nurses	78,810	43,670	212,760	43,790
Nurse practitioners	3,090	92,140	1,270	78,060
Nursing assistants	72,400	23,080	616,550	24,120
Occupational therapists	10,020	86,010	10,420	86,690
Registered nurses	168,970	63,810	148,970	60,180
Physical therapists	24,740	89,310	12,460	89,130
Physicians and surgeons	1,760	168,510	250	173,100
Community, personal, and social services
Counselors	2,440	41,260	910	38,020
Healthcare social workers	17,220	54,140	15,960	46,470
Personal care aides	303,980	18,670	22,470	21,410
Management, business, and administrative
Financial managers	1,340	95,940	1,210	91,570
Human resources specialists	3,670	45,990	3,730	46,590
Medical and health services managers	19,010	81,940	19,940	79,420
Medical secretaries	8,090	32,460	5,700	31,350
Receptionists and information clerks	5,210	26,550	13,180	23,900
Source: U.S. Bureau of Labor Statistics, Occupational Employment Statistics survey. Note: Estimates exclude self-employed workers.

Some hospice workers find their jobs rewarding for the same reasons they would in any industry. For example, a director or supervisor may feel gratified through staff achievements. “My role is to help my staff feel successful,” says Allen, “and success means when the patients are comfortable, their symptoms are managed, and the family feels supported.”

For other workers, job satisfaction may be more specific to end-of-life care. “Working in hospice absolutely mirrors the reasons I got into social work,” Wilcox says. “I can truly make a difference in people’s lives. A good day might be when someone quietly says, ‘Thank you.’”

People often choose these careers because they enjoy helping others and find hospice work as fulfilling as they’d hoped it would be. “The reward is the satisfaction of knowing that you’ve been able to help people at a time in their lives when they’re very vulnerable and scared,” says Kotajarvi. “It’s such a positive experience.”

Another advantage of these occupations, workers say, is creating bonds with the people they support. “I love my job,” Latta says. “We not only treat the patient, we treat families. You build some unbelievable relationships.”

Challenges

Among the stressors for hospice workers are the physical demands of patient care, such as standing for long periods, lifting or moving patients, and frequent travel for home visits. In addition, hospice services must be available around the clock, so some staff members need to work nights, weekends, or holidays or be on call to cover shifts.

Many hospice services are covered by Medicare, so these services have many government regulations that workers must follow. Keeping up with changes in the law may be difficult enough, but the rules sometimes leave workers feeling helpless. “The challenge is to be able to meet the needs of patients and their families,” says Kotajarvi, “especially when there are times that the law doesn’t allow it,” such as when personal care aides—who may not administer medication—cannot relieve a patient’s discomfort.

And even as hospice workers enjoy building relationships with patients and families, they acknowledge the drawbacks of getting close in these circumstances. “You do get attached,” says Latta. “It’s hard on the heart, hard on the soul.”

In some ways, the longer a relationship continues, the more stressful it may be for hospice workers. When a patient lives beyond his or her prognosis, for example, families may lose sight of the fact that the illness is terminal—and it’s the hospice workers’ job to remind them. “It’s hard having to be the one to say, ‘We’re here’ when the decline inevitably begins,” says Latta. “I see it as a positive: the long struggle for the patient is coming to an end. But it’s almost like the families forget what it means to be in hospice.”

Such challenges pale in comparison with the overall satisfaction of a hospice career, say workers. “People see a negative in working in hospice because all you do is work with dying people,” says Allen. “It’s not that it’s easy to work with dying people, but you know that your patient never felt deserted and that there was someone there to be his advocate. You know your patient was comforted by the fact that his loved ones were going to be supported even after he’s gone. It’s rewarding.”

Preparing for a hospice career

Workers enter hospice careers from different backgrounds. Some people move into hospice seeking a change in occupational or career focus. Others decide on hospice work because of firsthand experience with its services, such as through a family member.

Regardless of their path to hospice, prospective workers typically need some education, training, or experience to enter these occupations. (See table 3.) Hospice providers may offer additional training to employees who are new to end-of-life care.

Table 3. Education, experience, and training typically required for entry-level jobs in selected hospice occupations

Occupation	Typical education needed for entry	Work experience in a related occupation	Typical on-the-job training needed to attain competency in the occupation
Healthcare
Dietitians and nutritionists	Bachelor's degree	None	Internship/residency
Home health aides	Less than high school diploma	None	Short-term on-the-job training
Licensed practical and licensed vocational nurses	Postsecondary non-degree award	None	None
Nurse practitioners	Master's degree	None	None
Nursing assistants	Postsecondary non-degree award	None	None
Occupational therapists	Master's degree	None	None
Registered nurses	Associate's degree	None	None
Physical therapists	Doctoral or professional degree	None	None
Physicians and surgeons	Doctoral or professional degree	None	Internship/residency
Community, personal, and social services
Counselors	Master's degree	None	None
Healthcare social workers	Master's degree	None	None
Personal care aides	Less than high school diploma	None	Short-term on-the-job training
Management, business, and administrative
Financial managers	Bachelor's degree	5 years or more	None
Human resources specialists	Bachelor's degree	None	None
Medical and health services managers	Bachelor's degree	None	None
Medical secretaries	High school diploma or equivalent	None	Moderate-term on-the-job training
Receptionists and information clerks	High school diploma or equivalent	None	Short-term on-the-job training
Source: U.S. Bureau of Labor Statistics, Employment Projections program.

At nearly all levels of education, hospice workers need certain skills to be successful at their jobs. Other qualifications may be recommended or required, depending on the occupation.

Skills. Hospice workers should be compassionate but able to create emotional boundaries with patients and their families. They also must be organized, responsible, and self-motivated, says Allen, especially if they make home visits. “In a facility, someone is always overseeing your work,” she says. “But when you’re out in the community, there’s no way you can be micromanaged.”

Communication skills are critical for these workers. For example, hospice workers must be able to explain medical concepts—including some that may be confusing or even frightening—to families as well as patients. Hospice workers also need to collaborate with other members of the hospice team. And, depending on the occupation, they may have to write reports or make presentations to the community.

In addition, the task of having meaningful end-of-life discussions sometimes falls to hospice workers. “Every day, we have those very hard conversations with people,” Wilcox says. “We’re going to tell you the truth, even if no one else has.”

Another important element of hospice work is making sure that patients and their families feel supported. “Part of good communication skills is the ability to listen,” says Kotajarvi, “to hear their stories, not tell yours.”

And hospice workers need to have integrity and to be confident in their abilities, says Allen: “You are the patient’s and family’s connection to healthcare, and they need to be able to trust you.”

Education. Many of the occupations shown in table 3 typically require a bachelor’s degree or more education for entry-level jobs.

Students interested in hospice work can take classes in high school to help them prepare. For example, workers in healthcare occupations often study life and physical sciences, such as biology and chemistry. Community, personal, and social service workers usually learn topics such as human behavior and psychology. Management, business, and administrative workers need to know information systems and economics.

In addition to taking required subjects, hospice workers recommend studying marketing (helpful for community outreach) and developing networking skills (to connect patients and their families with local resources). And, of course, it’s essential to hone interpersonal, oral, and written communication abilities for nearly every aspect of hospice work.

Other qualifications. Some hospice occupations typically involve on-the-job training to attain competency. Others require both a degree and training; for example, dietitians must complete a bachelor's degree and an internship to become fully qualified.

Workers in some occupations need licensure or certification in order to work in hospice care. For example, every state requires medical and health services managers of hospice facilities to be licensed, and hospice aides must have a minimum level of training and pass a competency evaluation or get certification, depending on the state. Physicians, nurses, and therapists are among the other occupations that require licensure, certification, or both.

Optional certification in hospice and palliative care is available from professional organizations. For example, the National Association of Social Workers offers certification for licensed social workers who have taken continuing education courses in hospice and palliative care and have at least 3 years of supervised experience in those fields.

Experience

Of the occupations shown in table 3, only one—financial managers—typically requires work experience in a related occupation for entry. But prospective hospice workers can learn a lot through experience, even if it’s not required. “With students, I tell them that getting experience is something they’ll never be sorry about,” says Allen. “Variety is to their benefit.”

One way to get hands-on experience in hospice work is to volunteer with a provider. “Through volunteering, you can learn so much,” says Kotajarvi. “You have one-on-one contact with people. It’s a good learning tool.”

Hospice volunteers might prepare meals for patients or offer respite for caregivers, for example. Volunteers usually receive formal training from the hospice provider before visiting patients. Some hospices allow high school students to volunteer informally, such as doing administrative tasks, but these volunteers usually do not work directly with patients.

Another way to get a feel for hospice careers is to talk to workers or shadow them for a few days. Learning what it’s like to work with patients and their families is especially valuable if you’re not sure whether hospice is right for you.

Ideally, you should observe workers both on home visits and in an inpatient facility. Although workers may have more autonomy on home visits than in a facility, they usually see patients and their families more often in a facility and build deeper relationships as a result. Required travel for home visits can be physically exhausting, and the closeness created with patients and families in a facility can be emotionally draining.

Experiential learning in hospice care may help you to solidify career plans. “If you’re someone who wants to help people and wants to be in the medical field, hospice gives you a chance to do both,” says Latta. “I’m a nurse, but I’m also kind of a therapist. I’m working with families and guiding them through a very difficult time. It’s a very rewarding career.”

For more information

The occupations described in this article are just some of the many working in hospice care. For example, inpatient hospice providers employ workers in occupations such as building and grounds maintenance, food preparation and serving, and laundry and drycleaning.

Learn more about these and hundreds of other occupations in the Occupational Outlook Handbook (OOH). Published by BLS, the OOH provides detailed information about what workers do, what education and training they typically need, how much they earn, what the job outlook is, and more.

Other BLS resources include occupation profiles with employment and wage data from the Occupational Employment Statistics program and industry information from Industries at a Glance.

U.S. Department of Labor American Job Centers offer free assistance with career planning and jobseeking. Your state’s labor market information office may have additional resources.

General information about hospice and palliative care, including hospice facts, data, and career resources, is available from the National Hospice and Palliative Care Organization and Hospice Foundation of America.

Information about scholarships, fellowships, and other resources for people interested in palliative-care careers is available from the American Academy of Hospice and Palliative Medicine and the Center to Advance Palliative Care.

The Hospice and Palliative Nurses Association has information about education, scholarships, certification, and more for nurses at every level.

The National Association for Home Care & Hospice has information and resources about hospice and hospice providers. To learn about employment opportunities, contact a hospice directly.