Having it Their Way

Hospice gives new meaning to patient-focused meal service.

It’s lucky for Sheryl Edson Harding, RD, that minutes from San Diego Hospice and Palliative Care there are three major supermarkets and an upscale health food store. Having to drive a half-hour or more to get Mrs. Jones’ ham hocks would be a chore, and Harding’s position as the director of food and nutrition services leaves her little time during the day to shop. But she can squeeze in a few moments to stop at the market on her way to work.

FoodService Director - San Diego Hospice“It’s not uncommon at all for me to stop at the store to pick up something that we might not have on hand or that we don’t want to purchase in quantity,” she says. “Some of the things someone might want are not things we want a case of for the next person.”

Her willingness to spend time, as well as some petty cash funds, on foods for patients that the kitchen doesn’t keep on inventory is reflective of Harding’s primary objective, which is to stay as patient-focused as she can. The small size of the inpatient care facility—there is also a home-care division—makes it possible for her to be this flexible. There are 24 beds, and on any given day she may feed 20 patients or only seven, so the kitchen runs more like a small diner’s might—short-order cooking versus bulk cooking according to a cycle menu.

San Diego Hospice’s mission is to ease the symptoms and pain of people in latter stages of terminal illnesses until they can go home—whether that’s a private residence or a type of long-term care facility. Patients stay at the hospice three to four days on average, so the staff’s goal is to respond swiftly to the immediate needs of each individual. Since a patient’s condition may change often and quickly, mealtime decisions are made as late possible. “In normal acute care, someone from the foodservice department visits the patient and gets a menu from them for the next day—that doesn’t work too well in acute care; it doesn’t work at all in palliative care,” asserts Harding.

In the moment: At San Diego Hospice, staff members meet with patients between 9 and 10 a.m. daily to discuss what they want for lunch. Kitchen staff doesn’t get a handle on the day’s patient-feeding menu until about 11 a.m. Staff members encourage patients to order what’s being served that day in the facility’s visitor and employee cafeteria, such as the blue-plate special or one of the scratch-made soups, but the hospice certainly doesn’t limit patient’s choices to the cafeteria menu.

Patients are visited again around 3 p.m., at which time a staff member will talk about dinner options and help patients predict what they may want for breakfast the next morning. The objective is to minimize the time between when the patient orders and when the meal is served.

“You’ll have someone who has nausea and vomiting in the morning,” she says. “The doctors will change their medication, and by 2 in the afternoon, you are dealing with a totally different personality—someone who is now interested in food.”

Liberal approach: Cycle menus are too confining for the hospice. Cooks can’t predict how many patients will eat on any given day and what they may order, so the foodservice team there plans menus about two weeks in advance, bearing in mind considerations such as what’s in the freezer that should move before it freezer-burns and what’s in season.

This doesn’t prevent staff from having some foresight into what to stock in the kitchen. They can rely on patients to crave traditional favorites such as macaroni and cheese, meatloaf, mashed potatoes with gravy, puddings and custards—“things easily swallowed, easily digested,” Harding says.

She is lax about dietary restrictions, as long as a requested food won’t escalate a patient’s pain or make him or her more uncomfortable in some way. For example, proper insulin dosing may allow a diabetic to have a sugary dessert. On the other hand, she might cut back portions of the bacon, ham or tomato juice ordered by a patient suffering from edema because those foods have a high-sodium content that can exacerbate his condition. 

San Diego Hospice’s multi-ethnic, multi-cultural foodservice staff also helps meet demand for ethnic and American regional cuisine, whether it is Mexican, Filipino, Somali or Southern. Here again, nearby supermarkets come in handy; Harding ventures out occasionally to pick up items like gefilte fish, kimchee, dried fish, salted eggs, or grits—something she probably hardly ever did, if ever, in her three decades in traditional acute-care hospital foodservice.

Harding’s desire to accommodate her patients is a good fit with today’s patients. As baby boomers age and populate medical care facilities in increasing numbers, she has noticed that they are more assertive and demanding than their parents probably were.

Patient driven: But giving patients exactly what they want isn’t always possible. Not every request can be honored. Harding says she walks a tight rope between what she is legally required to do as a foodservice operator and what patients actually want. Rules regarding food temperatures are one example. “Many oncology patients like their food at room temperature to eat, and they’ll likely let [their meals] sit at bedside until they are ready to eat,” she says.

Like any foodservice provider, however, San Diego Hospice has to serve its hot food hot and cold food cold, and has to comply with the regulations every facility has to. Still, its core mission is about making people comfortable and creating a home-like environment. For the staff here, giving people what they need to feel at ease isn’t simply a nice touch, or a bonus—it’s the whole point.

So when a patient’s niece wanted to surprise her aunt with a visit and a special meal, the staff accommodated her. “We prepared the breakfast,” she recalls, “on nice tray with her crystal, family china and flatware, and the niece delivered it to her in the room.”

Some preferences, though, are easier to swallow than others. Harding admits that an order of white fish, mashed potatoes, cauliflower and white bread with vanilla ice cream may make her cringe. “That violates all our teachings about color and texture and variety,” she says. “But the patient is the center focus; if that’s what they want, we have no business injecting our values on it.”