xt7fxp6tzk40 https://exploreuk.uky.edu/dips/xt7fxp6tzk40/data/mets.xml The Frontier Nursing Service, Inc. 1984 bulletins  English The Frontier Nursing Service, Inc. Contact the Special Collections Research Center for information regarding rights and use of this collection. Frontier Nursing Service Quarterly Bulletins Frontier Nursing Service Quarterly Bulletin, Vol. 59, No. 3, Winter 1984 text Frontier Nursing Service Quarterly Bulletin, Vol. 59, No. 3, Winter 1984 1984 2014 true xt7fxp6tzk40 section xt7fxp6tzk40 \"_1•UIS1~c¢
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US ISSN 0016-2116 l
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FRONTIER NURSING SERVICE QUARTERLY BULLETIN  
US ISSN 0016-2116 ·
Published at the cnd of each quarter by the Frontier Nursing Service, Inc.
Wendover, Kentucky 41775 ~
Subscription Price $5.00 a Year '
Editor’s Office, Wendover, Kentucky 41775
 
VOLUME 59 WINTER, 1984 NUMBER 3  
Second·class postage paid at Wendover, Ky. 41775 and at additional mailing offices  
Send Form 3579 to Frontier Nursing Service, Wendover, Ky. 41775 l
Copyright 1984, Frontier Nursing Service, Inc.  

 ii QUARTERLY BULLETIN 1
l
I
l
·l
1
  CONTENTS
" 95th Class Enters Frontier School 2
FNS and the Hospice Movement — Part Two 4
Caring When Curing Fails 4
"Hospice Without Walls" -— A Practical Approach 12
I Photo Pages 18 and 28
Beyond the Mountains 19
by Ron Hallman
FNS Employees Receive Service Awards 20
Memorial Gifts 22
In Memoriam 23
In Brief 24
News of Former Staff 25
y Courier News 26
Out of Many, One 29
by William Terrell Cornett
Alumni News 30
Urgent Needs 33
Field Notes 34
Notes from the School 37
Note: We had originally planned to print in this issue a
` story on the FNS district clinic at Pine Mountain. The
l story of the clinic, however, ties in so intimately with the
history of the community, and in particular, with the
. history of the Pine Mountain Settlement School, that we
  felt we could not do itjustice by cutting it to fit this issue. It
is an interesting history, and it needs to be told. We
li promise to run it in the next issue.
l Cover photo and photos on pages 2, 5, 9,12,18, 28 (bottom), and 36 by
i Gabrielle Beasley.
l. Comments and questions regarding the editorial content of the
€ §~ FNS Quarterly Bulletin may be addressed to its Managing Editor,
" · Robert Beeman, at the Frontier Nursing Service, Hyden, Kentucky
  41749.
l
l

 2 FRONTIER NURSING SERVICE
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The New Students and Their Instructors: ll
Back row, left t0 right: Stephanie Stauber, Coleen Wold, Sandra Founds, julie l
Oulman, Sharon Leamon, FSMFN Family Nurse Instructor Nancy Fishwick Rl
(behind), and Sharon Machan.
I
Middle row, left to right: Gere Perona, Mary Dent, Mary Mays, and Ivy R
Kotovsky. I
Front row, left t0 right: Carla Stange, FSMFN Family Nurse Education R
Coordinator Sr. Kathryn O’Meara, and Nancy Ritenour.   V
t

 QUARTERLY BULLETIN 3
95th CLASS ENTERS FRONTIER SCHOOL
E As it does every year, January brought to Hyden a new group of highly
f qualified nurses to enter the Frontier School of Midwifery and Family
  Q Nursing. This year’s new class is the school’s 95th. Its members are all
x registered nurses whose working experience averages more than four
., years. Some of the students have worked in such distant places as
  Alaska, the Dominican Republic, Malaysia, and the United Arab
 L Emirates, and one has had previous midwifery training in England.
0   sr _ ¤ They were chosen from an impressive group of more than 40 experienced
· ’  nurses who applied for admission last year and followed through by
gt  I  A making the trip to Hyden, or to a designated West Coast location, for
    interviews.
  I All but one of the twelve new students plans to continue through the
    if   entire 16-month program, which awards a diploma and prepares grad-
A   A l uates for certification as nurse-midwives. The twelfth, upon completion
in p of the first three four-month trimesters, a program which also awards a
li diploma, will be prepared for certification as a family nurse practitioner.
  The new students, who are presented here in the same sequence in
  which they appear in the photograph on the facing page, are:
  Stephanie Stauber, RN, Bozeman, Montana, BSN, Montana State
"  University (1979). Coleen Wold, RN, Minneapolis, Minnesota; BSN,
  University of Minnesota School of Nursing (1979); MPH, University of
  Minnesota School of Public Health Nursing (1982). Sandra Founds,
` _ RN, Somerville, Massachusetts; BA (Psychology), State University of
I New York at Genesco (1976); BSN, Cornell University, New York
Hospital School of Nursing (1979). Julie Oulman, RN, Chicago, Illinois;
training in midwifery, Doncaster, South Yorkshire, England (1980);
ADN, North Iowa Area Community College, (1980). Sharon Leaman,
{ RN, Lancaster, Pennsylvania; Diploma in Nursing, St. Joseph’s School
[ of Nursing (1977). Sharon Machan, RN, Detroit, Michigan; BSN,
I { Wayne State University College of Nursing (1971).
Geré Perona, RN, Taos, New Mexico; ADN, College of Santa Fe
yl (1980). Mary Dent, RN, Luxemburg, Wisconsin; BSN, University of
i Michigan School of Nursing (1979). Mary Mays, RN, Verdugo City,
V I California; BA (Geography) and BA (Anthropology), University of Utah
  (1976); Diploma in Nursing, Los Angeles County, University of Southern
  A California Medical Center School of Nursing (1981). Ivy Kotovsky, RN,
  Jerome, Arizona; AAN, Yavapai Community College (1977); Licensed
i Midwife, Arizona School of Midwifery (1980).
Carla Stange, RN, Berkeley, California; ADN, Merritt College
(1981). Nancy Ritenour, RN, Pittsburgh, Pennsylvania; BSN, Univer-
A sity of Pittsburgh (1976).
I

 E?
Z
4 FRONTIER NURSING SERVICE  
FNS AND THE HOSPICE MOVEMENT — ?
PART TWO
The two articles that follow conclude a two—part study of "hospice-type" ·*F
care at the Frontier Nursing Service. The first part, which appeared in
the last issue of the Quarterly Bulletin, examined the hospice concept,
which attempts to deal more humanely with the problems of terminal ,,,
illness by accepting the fact of incurability, once that point has been
reached, and then devoting itselfto keeping the patient comfortable and ‘
helping him to live his last months with dignity and with a sense of  
being useful and productive. {
The final portion of this study, which begins below, describes the kind of  
care that FNS gives — and has traditionally given — to patients {
suffering from incurable disease, and also how FNS helps families to g
cope with the problems of terminal illness. The articles then discuss the  
findings of a study that FNS undertook last year to determine whether .
FNS should organize its "hospice-type" services in a more formal ·
manner, and, specifically, whether it should apply for a license to
operate "formally" as a hospice. In this discussion, the terms "formal I
hospice" and "hospice" are approximately synonymous with "licensed -
hospice” and generally refer to organizations that think of themselves ;
primarily as hospices and are organized and licensed to function as one.
FNS is not a hospice in that sense, although it provides a very similar '
kind of care. Q
CARING WHEN CURING FAILS  
The hospice movement has brought hope to many who have a l
terminal illness and to many others who want assurance that  
they would be well cared for if a terminal illness should strike V
them. Its great promise is relief of severe pain. Nevertheless, a
hospice remains "a place to die," and it might have little appeal if ‘
it were not that a disease such as cancer can be so dreadful when
hospice-type care is not available. ·
At the Frontier Nursing Service, hospice-like care blends into l
other kinds of care in such a way that no obvious line is visible  
between the care of the dying and the care of others whose illness,  
though serious, is not considered terminal. In part, this is because  
FNS has no formal hospice organization, which normally requires  
patients to acknowledge that they have a terminal illness and are ·
within six months of death. But in larger, and perhaps more T
significant, part, the FNS tradition of care has always encom-
r
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| passed many of the ways of caring that are now being offered by
l formal hospices.
  FNS has long been devoted to "joint practice" — a continuum
' of care provided by medical personnel of various specialties, who
move into and out of the caring process as their respective kinds
‘ of expertise are required. Beyond that, FNS has also had a
tradition of caring for people in their homes when appropriate,
and in so doing, it has established close, supportive, contacts with
° the families of those being treated. In practice, "hospice-type"
, care has been offered in many situations that would not be
Q handled by a formal hospice.
Q The value of this approach can be seen by comparing the case
E of a person who has a cancer that is clearly fatal and the case of a
5 person suffering from "COPD" — chronic obstructive pulmonary
2 disease. COPD is a general term that includes, among other
l ailments, black lung disease and emphysema. Such diseases may
l
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I

 6 FRONTIER NURSING SERVICE
be terminal, but do not have to be. But a COPD patient could not
be admitted to a formal hospice unless a physician certified that
he was expected to die within six months, and many COPD cases
are not that clear cut. In fact, most COPD patients at the Frontier g"
Nursing Service remain under care for periods of close to two l
years. For most of that time, they would not be eligible for  
treatment at a hospice. .`
At FNS, however, a COPD patient could expect to receive
hospice-type care once his illness reached a certain point. The fact .
of terminality may be more evident in a cancer case, but even so, it A
remains very difficult in the Appalachian culture for either a
patient or his family to acknowledge that an illness is terminal. A »
patient who is unaware of his condition, or refuses to acknowledge
it, cannot, as a rule, be treated at a formal hospice.
The "team approach" to chronic care is so traditional at FNS ’
that a terminal patient can move into a program of hospice-like {
care without any appearance that there is something special
about it. Usually, a terminal patient is referred to the FNS Home
Health Agency directly from the hospital, after the patient has
had tests or treatment. The Home Health Agency, directed by i
Diane Wilson, RN, has a staff that at this writing consists of four
registered nurses, who make regular visists to chronically ill ;
patients in their homes. When a patient is referred to Home 1
Health on a doctor’s orders, one of these nurses will be assigned to 1
take care of him. ·
The team is further built up by calling in Pat Campbell, RN,  
the Oncology Nurse, who describes herself as a "resource person"
(though she is more than that) and helps bring together other
persons who can be of help. Ruth Ann Dome, BSW, the Social F,
Work Coordinator, is one of these "resources" on whom the team
may call. Eventually, the "team" may be expanded by asking for l
the help of the patient’s minister, neighbors, and others. The ,a
entire effort is coordinated by the patient’s physician.  
The first step is to determine whether the patient can in fact be g
cared for at home. (Most of them can be.) The basic requirement is ¥
that there be a key person who can take responsibility for the
patient’s home care and is willing to do so. Not every family can V
cope with terminal illness at home, but sometimes a relative, `
friend, or neighbor can take on the assignment. If home care is ·

 QUARTERLY BULLETIN 7
not feasible, the patient will be provided for in some way, usually
by returning him to the hospital.
J, The strength of family ties in Appalachia is well known. Most
Q patients want to be at home if that is at all possible, and most
Q families want to have them there. This natural urge for "together-
Q, ness" is reinforced by widespread feeling that a nursing home is
· "a place to die," so that no one ever considers that option. In fact,
there are no nursing homes in Leslie County, probably because
; they could not expect much patronage.
Eager as a family may be to care for a loved one at home, they
may be overwhelmed by doubt and anxiety. What kind of care
» —in specific terms — will they be asked to give? Will they know
what to do and how to do it? Do unmanageable problems lie
ahead? Does the family have the emotional and physical stamina
to contend with a prolonged period of constant care? Can they
i manage financially? Can they cope if an emergency occurs in the
middle of the night?
The team works with them on these issues. The family is told
_ what it needs to know about the expected course of the illness
’ —what symptoms there may be, how the patient is to be treated,
and how he may react to treatment. Arrangements are made to
I provide equipment for use in the home, starting as a rule with a
y hospital bed. Other equipment, such as that used? for IV’s,
J injections, drainage, etc., or items like bedside commodes, can be
_ rented to the family when needed. Instruction and equipment
T may come from Home Health, the Medical/ Surgical Department,
A or the oncology nurse, as appropriate.
I To a far greater degree than anyone expected, families have
si learned to give many kinds of care for which patients have in the
’ past had to go to a hospital. For example, family members can
l take care of nasogastric tubes (leading through the nose to the
ll stomach and used for feeding or draining), colostomy drainage
equipment, gastrostomy tubes (for feeding patients who cannot
f eat normally), and so on. They learn to give injections and to
’ attend to lV’s. Recently a patient was fitted with a Hickman
catheter, which may be thought of, basically, as a tube that is
threaded through a vein to the heart, with the outer end passing
through the chest and closed externally by a removable cap. The
‘ catheter can be used for feeding, or for administering medication,

 8 FRONTIER NURSING SERVICE C
especially that used in chemotherapy, and it can also be used to
draw blood. (Chemotherapy treatments are routinely given at the
hospital by Pat Campbell; they are not handled by the family.) _ 
The catheter is installed in a relatively easy minor operation (in "'
this case, at a Lexington hospital), and then can be used by the Q
patient at home. This particular patient was pleased with the one lg
given her. She found it comfortable and said that fitting it had not ,`
been a problem. S
Meanwhile, the team also begins to look into non-medical
needs. If the cost of care will be a problem, as it generally is,
financial advice is given, usually by the social work coordinator.
If the family will need help with shopping, cooking, housekeep- l
ing, or the like, a team member may try to get the assistance of one Z
or more relatives or neighbors. The patient’s minister will usually
be called in to provide spiritual care. The team will confer
periodically to be sure that all needs are being met.
One of the most important considerations is morale — the
patient’s and the family’s. To the extent that it can be provided,
psychological assistance will be given to the patient and family
—- and also to team members, who may need both technical
guidance and help in dealing with their own emotions. (Caring
for a terminally ill patient can be emotionally draining, even for
the expert.)
It is stressed constantly that the "unit of care" in hospice
treatment is the combination of patient and family, not just the 4
patient. The patient’s needs, of course, go beyond physical
comfort. He will also need emotional support. He is likely to be ,
anxious and fearful, and perhaps depressed. This in turn can Y
affect family morale as family members pick up the patient’s V,
fears and worry with him. Meanwhile, family members have  
their own fears and doubts about how well they will be able to g
stand up to the ordeal ahead. This can upset the patient. He will l =
wonder "how they are taking it." Typically, the patient "doesn’t
want to be a burden." All of these concerns must be dealt with
constructively. _
If both patient and family can face the fact that an illness is  =
terminal, it is usually much easier to deal with morale. If they do
not, added emotional stresses can be created. Everyone becomes l
involved in "fencing" — parrying questions, trying to control ,
emotions that might better be vented honestly, struggling to

 ` QUARTERLY BULLETIN 9
weave and preserve a fabric of "white lies" in the hope (usually
l vain) that it will make the situation easier.
'_% Diane Wilson, of Home Health, stresses the importance of
working through "the five stages of dying" with a terminal
» patient and his family. (She is speaking here of the well-known
_ thesis of Dr. Elisabeth Kubler-Ross, who contends that a dying
, patient typically passes through periods of denial, anger, bar-
_ gaining, depression, and acceptance.) Team members try to help
patients and families by "talking their way through" these stages
(which each member is likely to pass through in his own way, at
his own time), ultimately reaching a stage where fear and distress
are replaced by peace of mind. Diane points out that if a person
refuses to accept the fact of terminality, there is simply no way to
. work past the denial stage.
The family must also begin to deal with bereavement, even
. while the patient is still alive and active. Despite a traditional
_ Anglo-Saxon persuasion that a show of emotion is a show of
weakness, the experience of many counselors has been that it is
l  
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V Oncology Nurse Pat Campbell administers chemotherapy to Lillian Murr through a
· Hickman catheter. Although patients must come to the Mary Breckinridge Hospital for
` such treatments, their families are trained to use catheters like this one at home for such
4 purposes as feeding patients who have trouble eating. Mrs. Murr became one of FNS'
L best loved patients. Her husband cared for her at home and she came to the hospital
` only in the very last days of her illness.

 io FRONTIER NURSING SERVICE l
much better to deal honestly with feelings. It has been observed j
that family members who participate actively in caring for a
patient are less likely to suffer guilt afterwards. Also, it has been `1
found that there is something about going through a period of  
I open, unashamed grief, including the funeral, that somehow  
helps the family adjust to loss. S
Making the patient comfortable has several aspects. Relief of ‘
physical pain may be an obvious example, but it is not the only
one. Pat Campbell describes how many "little" touches can make
a patient more comfortable, adding that these can be discovered
and applied by working with a patient over a period of time
—FNS’ traditional continuity of care. The nurse (very often Pat S
herself) may learn that a patient is most comfortable (or uncom-
fortable) in a particular position, or has preferences in foods that
matter a great deal to him. Pat spoke of a patient who could not p
easily swallow a certain pill but would take it gladly if it were
I ground up and mixed into applesauce. Often these little things
make a critical difference in morale and comfort.
A recent study of FNS’ terminal care testifies to this. Here is
part of the report: i
The level of patient satisfaction was high. [Interviews with patients .
suggest] that the oncology nurse provides: (1) continuity of care; (2)
patient counseling; and (3) coordination of care, especially when
the patient is referred to other facilities for treatment/ diagnosis. g
Such comments as, "Pat (the oncology nurse) meant more to me
than anything; she told me to call any time — and just knowing she
was there meant a lot." Other patients reported that the oncology
nurse was there during or immediately after being informed of their
condition — "she was there and totally supportive." "She was
helpful and told me what to expect." One patient reported "breaking [ i
down" after being informed that she needed a radical mastectomy. F
"Pat took me in her office and talked — she provided immediate {
emotional support. Later she provided information about actual Kt
surgery and what to expect. She assisted me in being admitted I
—went upstairs with me. She told me she would be there after
surgery, and she was/’ .
Understandably, families can become very anxious at the
prospect of handling emergencies at home. The team therefore »
makes sure they understand what, specifically, to expect — *
whether a particular situation may lead to hemorrhage, coma,  I
nausea, or some other difficult situation. They learn what to do in I

 1 QUARTERLY BULLETIN 11
j such cases. Above all, the family is reassured that help is
available 24 hours a day. This is provided in each case through a
A1 plan worked out by the physician, Home Health nurses, and the
  oncology nurse. The emergency room at FNS’ Mary Breckinridge
i Hospital provides additional backup.
A, Although some patients do die at home, a time comes for most
` when they must be moved to the hospital. Here the patient finds
that care continues to be surprisingly — and most reassuringly —
"home-like." As always in "hospice" cases, the primary concern
is the patient’s comfort. To this end, the hospital tries to make the
patient’s room as much "like home" as possible. First, it will be a
A private room if one is available. The family may bring in a few ·
pieces of furniture from home. Familiar pictures may be placed
within the patient’s view. Visiting regulations will be relaxed.
. Family members may be allowed to stay overnight. Children are
welcome. A favorite dog or cat may be permitted to visit.
A patient may be convinced that no water tastes as good as the
water from his own well; the family may bring in a supply of it,
and the hospital will keep it for him in the refrigerator. Often
i someone will cook and bring in a dish that the patient particularly
, enjoys.
Sometimes the hospital room is filled with members of the
patient’s church, who have come in for a period ofprayer, or for a
{ "laying on of hands." At times, the outpouring of feeling can be
very vocal. There has even been a baptism in a patient’s room.
Since it is the patient and his family that make up the "unit of
care," care will continue beyond the patient’s death. After the
death, the team refocuses its efforts on the family in its bereave-
gi ment. If the death has occurred at home, as it does in some cases,
l the Home Health nurse may have spent the last night with the
[ family. In any case, she will now be on hand to offer what comfort
W she can, and she will attend the funeral. Afterwards, she will help
A them as they adapt to life without the deceased. The team will
keep in touch until it is no longer needed. Typically, the nurse will
A visit the family regularly for about six weeks. After that time,
nurse and family communicate more by telephone and less by
 ’ personal visit. As a rule, need for "active" contact fades away
A gradually over a period of about six months, but very often the
‘ nurse will find that she has become "a part of the family." The
T relationship may last a lifetime.

 12 FRONTIER NURSING SERVICE
l
The wide-ranging care described here is natural to FNS, and it l
also happens to be very much the same kind of care provided by a Z
formal hospice. Each has reached this level by a different route. _,
Recently, the question has been raised whether FNS should try to
establish itself formally as a licensed hospice. As noted earlier, a
study has been done on this subject and a report issued. The study B
came to some interesting conclusions, and these are discussed in _
the next, and final, article in this series.
1   I     ·__.   .2.; I I   .,..   I y ``;i‘ §;.g_  
   ’      I     f ti     I              
    iii: ¥=·=*"‘ iii 1 · ?   ,
  _ _.f  ciiiwnill _ f i   I  
    »   V I if " lg,   ..  ‘_ .
    '`‘‘ i, » .   ei s   ‘ I
      ’  `°___·;,7J2l'¥·l*"`“ _       _
  -·.. · ` ’ V     Y ifs ill".  I
· , . ..~.* , g; ¤ ;;, my
A   ·``i e :’··   z. ’  I .i`Yi;?1 ».`e
Diane Wilson, at left, is the director of the FNS Home Health Agency. Here she confers
with Pat Campbell, the FNS Oncology Nurse.
l Z
"HOSPICE WITHOUT WALLS" — lg
A PRACTICAL APPROACH ·
When anything becomes popular, it is likely to become regulated. S
Pioneers can improvise, establishments cannot. So must it be (or
so it seems) with hospices. As the public awakens to the promise
of hospices, so governments awaken to a new need to exercise
control.
There are reasons for this. No public wishes to be victimized by
unsafe medical practice, and so it looks to government to be sure

 QUARTERLY BULLETIN 13
D that none is allowed. At the same time, the exercise of control can
y so complicate the administration of a new program of care, and so
I increase its costs, that the program loses much of its expected
" promise.
But first, some history. The hospice concept evolved initially
E out of a desire to care more humanely for the terminally ill. Few
realized that it could have an additional reward — lower costs.
Aware of the growing interest in the hospice movement, the
Frontier Nursing Service became involved, starting in 1978, in
studies to determine the feasibility of a hospice program in
Kentucky. The first effort took the form of a Hospice Conference
sponsored jointly by FNS and The Ephraim McDowell Cancer
Network. The following year, FNS participated in a grant from
the National Cancer Institute. This in turn led to the development
of a concept called "hospice without walls," which loosely defined
a program of hospice—like care under less formal auspices. In 1980,
FNS began a three-year program, under an NCI Oncology Rural
~ Demonstration Grant, to develop this concept formally for Leslie
County.
A history of the hospice movement in the United States would
be in part an account of efforts to develop standards for hospices,
and in part a record of efforts to bring hospice care under
Medicare. Both are closely related. The details of history need not
be described in this article. What matters here is the form now
taken by the Medicare standards and the prospects for hospice
care and costs under that program. The standards have gradually
evolved into a set of regulations which indicate rather clearly the
course to be expected of Medicare.
ri In the first place, a "formal" hospice will have to be licensed as
i ‘ such. That immediately imposes certain administrative and legal
5 obligations, beginning with legal responsibility for the operation
g of the hospice. This is expectable and reasonable, but it would
.` also impose (or so it appears) legal responsibility for care
p provided by subcontractors.
` Although many hospices would be based on an existing
hospital (as would be the case at FNS), the hospice function would
have to be organized and administered as a separate entity. Its
V record keeping, plans of care, personnel policies and procedures,
and so on would need to be maintained separately from those of

 14 FRONTIER NURSING SERVICE
the parent hospital. The hospice would require its own administra- -
tive manager and its own medical director, who must be a
licensed physician. In a large hospital, this distribution of
functions would be sensible. In smaller hospitals, where related vi
functions may need to be combined for efficiency, insistence on a  
separate organization could require expensive duplications.  
Regulations concerning care follow the principles that FNS I
itself has followed for years in giving "hospice-type" care, as
discussed in the first two art