Hospice is focused on doing the very best that you can with the circumstances present.  After it is established that no cure exists for the illness of a loved one, the idea of “hope” takes on a different meaning.  There is a shift in the paradigm of hope, as it then means to do everything possible in order to satisfy the loved one’s wishes and to reduce their pain and suffering.  The focus shifts to comfort care provided in the familiar environment of their home, with family and friends near.

Hospice is the Next Critical Step of Care in the Continuum 

When clinical providers have come to the point where nothing more can be done for a patient, because there is no imminent cure for a particular condition, hospice care offers the next critical step of care in the continuum.  Contributing to the quality of life for the patient and their family is of the utmost priority, and hospice allows for goals related to quality of life to be met.

Focus Shifted to Spending Quality Time

It is likely that before a terminal diagnosis is reached, the patient’s loved ones are consumed with various concerns such as physician appointments, evaluation of possible treatments and cures, attempting to manage pain and symptoms, and more.  Upon finalizing and accepting a diagnosis, utilizing hospice care can provide an extremely significant relief, where spending quality time can be the new focus for loved ones and the patient can receive the quality care they deserve.

Solicited Care

When patients with terminal illness elect to utilize hospice care, the additional care can allow for patients to potentially live a bit longer than those who do not receive hospice care.  With the comfort associated with living at home, surrounded by loved ones, hospice patients can also experience a strong sense of relief, and furthermore, more control and choice within their circumstances.  The differentiated, and specialized care that is provided by the hospice interdisciplinary team can not only reduce suffering, but also allow the patient and their loved ones to spend more quality time together, and ultimately give back to the patient a sense of dignity.

Enrolling in hospice care is not giving up!  Hospice care is another aspect of patient-centered care within the continuum that provides to patients and their families the support they need to live their final days at home with an improved quality of life, and surrounded by those they care most about.


In hospice care there is a need for difficult conversations that lead to even more difficult decisions by healthcare providers, their patients and families. Of the most challenging conversations is that about commencing, maintaining or removing artificial nutrition and hydration (ANH) as a patient nears the end-of-life.

These decisions are complex for various reasons, including medical and ethical guidelines, along with the consideration of the emotions of patients and their families.  In addition, difficult questions about withholding food and water at the end of life will arise, and the religious, cultural, spiritual and personal factors that are involved with a loved one’s forthcoming death further complicate the conversation.

Hospice care providers can maneuver these difficult decisions by fostering engaging conversations that are rooted in empathy and well-informed by their expert clinical knowledge, skills and experience. 

Create an Individualized Plan for Hospice Care 

Proactive care planning demonstrates an optimal method for the patient and family to clearly explain the wishes and values of the patient before the patient becomes unable to do so. Providers can inform patients and families of the process of natural death, inclusive of the role that ANH may play.  The interdisciplinary team can be an indispensable source that they can rely on to effectively conduct such conversations so that all standards, including medical, ethical and professional, are met, or exceeded.

Since each patient’s prognosis, needs, and objectives of care vary, the decisions regarding ANH should always be established after thoughtful, transparent and informative conversation that needs to address the following:

  • Specific diagnosis and prognosis (how ANH will impact each)
  • Medical issues (the implications for or against ANH)
  • Non-medical issues (the personal, cultural and religious beliefs and values of the patient and their family and how these can be respected in the hospice plan of care)
  • Quality of life (if ANH will increase or decrease suffering)
  • Goals of care (if the decisions related to care will reinforce the wishes and values of the patient)

Provide Education to Family Members About the Dying Process

Current research does not support the claim that withholding food and water at the end-of-life contributes to suffering and/or the prolongation of life.  This should be incorporated into the discussions with the patient and family as well as the creation of the specified plan for hospice care. Furthermore, as the condition of the patient changes, the plan for hospice care should change appropriately also.

It is important that the clinical staff in the interdisciplinary team mitigate the associated emotional issues by reassuring the family that the team is not “giving up on” or “starving” a patient in hospice care who stops eating or drinking.  On the contrary, the team should provide education to their patients and families regarding the human body’s natural dying process, including the fact that the digestive tract shuts down with an increasing incapacity to process food and liquids. Patients’ families can find reassurance in understanding that as food and liquid intake decelerates, the patient’s body often also releases the “feel-good” endorphins naturally to relieve pain.

The Benefits and Risks/Complications of Tube Placement: 

For hospice patients the following overall guidelines address feeding tubes:

  • Existing feeding tube: If patients are enrolled in hospice with already existing feeding tubes, physicians should work closely with patients, their families and any other caregivers to make decisions with regard to if and when to reduce or cease ANH. As a patient nears the end of life, ANH can be responsible for discomfort, aspiration and development of bedsores, absent of the advantage of prolonged life.
  • Placing a new feeding tube: Typically, feeding tubes are not placed for patients once they are admitted into hospice care. Rarely, a decision will be made, with collaboration between the patient, family and interdisciplinary team, to proceed with implementing a feeding tube.

Generally, research shows that ANH does not extend life or lengthen longevity of survival.  However, it has shown that it can be connected with various difficulties that decline the quality of life for the patient.  Typical difficulties caused by ANH include irritation, infection, blockage, discomfort, aspiration pneumonia, bleeding, reflux, uncontrolled diarrhea, limited socialization/movement, frequent replacement or removal of tubes, a lack of proper oral care, and elevated utilization of physical and/or chemical restraints. Tube feeding near the end-of-life can also develop sensations of “drowning” or uncomfortable “fullness” for the patient.

As an example of prognosis-based guidelines, the American Geriatric Society, American Academy of Hospice and Palliative Medicine, and The Society for Post-Acute and Long-Term Care Medicine do not recommend feeding tubes for patients with advanced Alzheimer’s/dementia, but instead, recommend oral assisted feeding, (Teno, J., et al, 2014).

Frequently Asked Questions from Healthcare Providers Regarding ANH at End-of-Life:

  1. Do feeding tubes prevent malnutrition?  Not necessarily, as many people that are on hydration and feeding tubes still experience malnutrition due to their underlying disease, immobility, and/or neurologic deficits (but not typically from a lack of food and water).
  1. Do feeding tubes prevent bedsores or expedite healing?  ANH can increase urine output, stools, diarrhea, upper airway secretions, and immobility, which can all intensify and increase bedsores, as well as interfere with the overall healing of existing wounds.
  1. Do feeding tubes reduce the mortality rate?  According to research, life expectancy is virtually identical for patients who are offered ANH at the end-of-life with those who are not offered it.
  1. Do feeding tubes prevent aspiration pneumonia? Current research does not support the claim that feeding tubes reduce the risk of aspiration pneumonia or regurgitated gastric material.  On the contrary, some evidence indicates that there is an increased risk of aspiration, as patients with tubes can still aspirate gastric material and oral secretions, or even suffer aspiration pneumonia from other natural causes.

Educate Families About End-of-Life Care

Healthcare providers are instructed to encourage patients’ families to adhere to the following established guidelines for hospice patients with regard to hydration and nutrition near the end-of-life:

  • Provide small sips of water or liquids, ice chips, hard candy or significantly small amounts of food with a spoon if the patient is still able to eat and/or drink. Adhere to signs from the patient for when to stop.
  • If a patient is no longer able to drink, maintain moisture of their mouth and lips with swabs, a wet washcloth, lip balm or moisturizers.
  • Encourage family members to offer alternative forms of nourishment such as engaging conversation, loving touch, music, poetry, humor, visits from pets, gentle massages, reading, prayers or other behaviors of compassion and love.


Teno, J., Meltzer, D. O., Mitchell, S. L., Fulton, A. T., Gozalo, P., & Mor, V. (2014). Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia. Health Affairs, 33(4), 675-82. Retrieved from


Hospice is designed to foster quality of life with an emphasis on pain and symptom management. The deterioration of the skin that is detected from pressure ulcers or other wounds is a sign that the systems of the body are diminishing, and even completely breaking down.

Even when nearing the end of life, effective wound care can significantly influence comfort physically, psychologically and emotionally.  Wounds tend to ignite feelings of fear, hostility and even suspicion of negligence.  Inadequate care, or a lack of care for wounds can be extremely detrimental to the patient, and furthermore, negatively affect the experience of the family  throughout the very difficult time of losing a loved one.

Hospice Patients and Bedsores

Pressure ulcers, which are also known as bedsores, are very common among hospice patients, with over 40% of them experiencing them. Despite insistent preventive measures, and usually as a result of diminished muscle, cell, and immune function, among other factors, severely ill patients experience compromised response to healing.  For these patients, the development of bedsores may be a visual biological indicator that their severe illness has overwhelmed the body and it is important to note that the breakdown of skin is not fully preventable or treatable.

It is a possibility that once bedsores develop in terminally ill patients, family members may see this as a failure of the interdisciplinary team or the family caregivers themselves to provide adequate care.  Furthermore, their response, oftentimes being emotional, can lead to demands that are jeopardizing to the patient’s plan of care that is rooted in comfort.

Nonetheless, attempting to prevent and treat these concerns cannot get in the way of the hospice tenet of providing comfort-based care.  Research shows that comfort should overrule preventive measures in situations where advanced illness causes patients to be more comfortable in a particular position.  If the hospice interdisciplinary team determines that regularly scheduled patient movements increase their pain, these movements may be suspended.

Other Wounds Common in Hospice

Since hospice teams care for such an extensive variety of patients and conditions, there is an equally wide variety of wound types that they encounter, such as arterial insufficiency wounds, diabetic ulcers, venous ulcers, and tumors or fungating lesions.

Risk Factor Evaluation and Preventive Measures

Upon admission, conducting a comprehensive risk assessment is crucial, and needs to include a check of the patient’s entire body.  Bedsores are caused by both internal and external factors, including the lack of mobility, cognitive function deficiency, an  inability to verbalize discomfort or sensations like numbness, chronic sickness, aging and poor nourishment.

After the risk factors have been identified, the best practice is to prevent wounds from developing in the first place.  Measures for prevention include, but are not limited to consistently inspecting the skin of the patient and observing for appropriate moisture maintenance.  Also, suitable positioning, proper techniques for transfer, and nutrition are crucial with regard to the patient’s comfort.

Avoid pressure on the heels and bony prominences of the body, and use positioning devices whenever feasible. As always, remember to document the condition of the skin after assessment.

Staging (Categorizing) Wounds

The National Pressure Advisory Panel established the following wound stages, (NPIAP, 2017):

  • Stage I—Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue wound. 
  • Stage II—Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 
  • Stage III—Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable wound. 
  • Stage IV—Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable wound. 
  • Deep-Tissue Injury—Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness wound (Unstageable, Stage 3 or Stage 4). Do not use deep tissue wound to describe vascular, traumatic, neuropathic, or dermatologic conditions. 
  • Unstageable—Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 wound will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 

Basic Principles of Wound Care

It is imperative to first establish an effective plan for wound care that includes determining the prognosis of the patient, their condition and the potential they have for their wound(s) to heal. For example, it would be fitting to have a less aggressive approach for a patient nearing end-of-life, or when it is clearly displayed that it is not realistic they will heal.


Setting appropriate goals that are determined by the prognosis, condition and potential for healing is essential, and within hospice care, these goals might include:

  • Prevention of complications with wounds (i.e. infection or odor)
  • Prevention of further skin breakdown
  • Minimization of harmful effects on the patient’s overall status as a result of wound(s) 

During the process of creating patients’ care plans, it is imperative to consider, and furthermore, incorporate their condition and their wishes.  This plan needs to be re-assessed regularly (typically biweekly) to ensure that it is still appropriate for the patient.  When a wound does not heal it does not always mean that other methods or treatments are necessarily more fitting, or that the interdisciplinary team should try all other treatment options.  The team should rather work to differentiate the plan to utilize the most appropriate options for that given patient based on their condition and wishes at that given time.

A standard plan for wound care will include the following:

  • Cleaning the wound of debris
  • Possibly debridement
  • Absorption of any excess exudate
  • Promotion of healing
  • Treatment of infection
  • Minimization of any discomfort

When a patient is in hospice care, wounds can be significantly stressful for the patient and family with regard to the associated pain, appearance, odor and furthermore the perceived implications of wounds. To maintain the goal of hospice of comfort-focused care, the interdisciplinary hospice team needs to function with diligence and detail to assess and document wounds and any changes to the patient’s condition while also conducting appropriate methods for prevention, and establishing and updating the care plan in consideration of the patient’s needs and wishes.

By decreasing the incidence and intensity of wounds and diminishing their impact, the hospice team provides an improved quality of life, and fosters an environment that allows for a peaceful death experience for both the patient and their loved ones.


The National Pressure Injury Advisory Panel. (2017). NPIAP pressure injury stages. Retrieved from


Research has shown that a great majority of patients desire to know the truth about their condition, (Buckman & Kason, 1992). When patients are not provided with this information they report feeling alone and abandoned. The challenge is for health care providers to take the time to have these important conversations with patients and their families, as well as consistently provide updates to statuses, given that today’s environment often leaves clinicians constrained with regard to their time, (Kinzbrunner & Policzer, 2011). 

Healthcare providers have the opportunity to offer a precious and invaluable gift to patients and their families by discussing the patient’s options near the end-of-life, while still allowing the patient to enjoy quality of life.  A patient who is informed, and has an understanding of the options they have along with what hospice care can provide will have a stronger sense of control in their situation.

Similar to evaluating the health history of a patient or facilitating a physical, introducing pertinent end-of-life conversations with patients is an attainable skill that can be learned.  When done so effectively and thoughtfully, these discussions allow for stronger relationships between physicians and their patients, and improve the chances that patients will decide the most optimal treatment options, including hospice care.

Obstacles Within Talking About Death

  • Worry with regard to the patient’s reaction:  Regardless of the fact that patients want to know the truth about their conditions, they might have a strong emotional reaction or physical outburst initially related to the thought of having limited choices, a loss of control, a deteriorating lifestyle, changes in their image of self, and ultimately losing their life, (Kinzbrunner & Policzer, 2011).  Although these more intense reactions might trigger discomfort for the provider, properly preparing for the conversation along with specific consideration, or even empathy for the patient’s perspective will help to deescalate the situation.
  • Worry with regard to the provider’s reaction:  The provider may be concerned about appropriately responding to a patient’s anger, anxiety or sorrow.
  • Idea that the provider won’t be able to “do enough”:  Providers can even strengthen the relationship with the patient through exhibiting compassion and honesty while recognizing their own thoughts and feelings regarding the decline of a patient notwithstanding all efforts.  Discussing the options for end-of-life care is the next practical step in the continuum of care for the patient.
  • Leading such discussions triggers anxiety:  This obstacle is the easiest to conquer when the provider takes the time to become informed on how to effectively conduct end-of-life conversations thoughtfully and with compassion and empathy.  This learned skill will not only assist patients in making informed decisions, but also ease the discomfort of the provider.


SPIKES has six pragmatic aspects:

In case a person is diagnosed with a terminal illness, or is approaching death and is unable to communicate for themselves, end-of-life experts recommend that the following steps be taken proactively to ensure that the patient’s wishes are actually acknowledged and executed.

  • Setting – Decide on a private setting where you can sit in person with the patient and their loved one.  If the patient does not speak the same language as you, depend on a professional interpreter as opposed to a family member.  
  • Perception – Gauge the perception of the patient by asking how much they know, perceive or suspect before commencing the conversation.
  • Invitation – Discreetly invite the patient to provide information about their willingness to receive more information, by asking if they want to discuss test outcomes, treatments, etc. If the patient does not respond favorably, recommend that you try having the discussion at another time, possibly later that day or the next, and then make sure to follow up with them at the decided time.
  • Knowledge – Provide information directly and concisely, and once you have opened the discussion, stop talking in order to listen to the patient’s responses, thoughts and emotions.
  • Empathy – Acknowledge, and identify with the patient’s emotional reaction in a compassionate and kind way that suggests you not only understand, but appreciate their response and are genuinely concerned about their future as well.
  • Summation – Summarize the information and recommend they consider hospice care.

“SPIKE” Your Communication Skills and Your Confidence

As you follow the SPIKES system, you can increase your ability to facilitate effective discussions about end-of-life treatments and embracing hospice, (Buckman & Kason, 1992).

This will help you assess:

  • A patient’s understanding about their condition
  • A patient’s readiness to discuss end-of-life overall
  • The optimal way to adjust to a given patient’s response
  • The significant value of both silence and observation
  • How best to interpret a patient’s reaction, regardless of its appropriateness
  • How to inform your patients in a way that exhibits empathy
  • The role hospice care can play in maintaining hope, comfort and dignity

The Role Hospice Plays

Hospice plays an essential part with regard to the satisfaction that a patient and their family experiences at the end-of-life. Optimal hospice care is supplied for months, as opposed to weeks or days. Hospice care can assist in managing pain and symptoms, providing comfort, and addressing the spiritual and emotional needs of the patient and their family when intensity and/or side effects of treatment start to surpass any anticipated advantages.

Hospice care provides patients a sort of gift of time, enabling them to visit with loved ones, enjoy time outdoors, experience family milestones and to get affairs organized.


Buckman, R. & Kason, Y. (1992). How to break bad news: A guide for health care professionals. The Johns Hopkins University Press.

Kinzbrunner, B. M. & Policzer, J. (2011). End-of-life-care: A practical guide. McGraw Hill Professional.

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES – A six step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302-311.


In an article published in the Journal of Clinical Oncology, the authors provide a review of relevant research with regard to end-of-life care for cancer patients, and they identify the ways that hospice care assists patients with advanced cancer and their loved ones who become caregivers. Ways in which hospice care can improve are also highlighted.

Priorities for Cancer Patients at the End-of-Life

The researchers observe that several studies have sought to explore the priorities of patients with advanced cancer and that of their caregiver for end-of-life care.  Some of the most commonly indicated priorities were related to the following:

  • Pain and symptom management
  • Feeling well enough to spend time with loved ones
  • Dealing with matters of business and legacy that had yet to be taken care of

As a result, the researchers state that “hospice care services have grown rapidly to support families and communities to care for people at home (including in skilled nursing facilities) through excellence in physical symptom control, psychological support, spiritual care, and support for caregivers.”

Mitigating the Burden of Symptoms

According to the research, hospice care allows for improvement of symptom management in issues that are commonly expected at the end-of-life. Symptom mitigation for advanced cancer patients nearing the end-of-life often involves addressing one or more of the following common symptoms:

  • Pain
  • Fatigue
  • Breathlessness
  • Delirium

The inability to feel pain was identified by the article as commonly the priority for patients and their loved ones over any other symptom. The evidence suggests that hospice care offers superior pain management to patients. Furthermore, it is noted that another priority symptom, delirium, which includes changes in cognitive function, illusions from hallucinating, and disruptions of sleep and wake cycles, can be treated with excellent nursing care.  Nurses can treat reversible causes, assist in orienting the patient, and provide appropriate hydration and nourishment.

Optimal Integration within End-of-Life Care

The researchers encourage practitioners to explain the prognosis of rapidly declining advanced cancer patients with them, and refer them to hospice services. Optimal end-of-life care for cancer patients, as noted by the article includes:

  • Every Health Professional Having Competency in Core End-of-Life Care Skills:  This consists of identifying the end-of-life status, understanding the key tenets of symptom management and interdisciplinary care, conducting patient-centered, effective communication and shared decision-making, executing excellent clinical skills in thorough bedside evaluation, and engaging with empathy and compassion.
  • Care from a Team-Based Approach:  The article explains that patients tend to be more likely to express their concerns and disclose information about more issues when an interdisciplinary team is providing care and since the patient-identified needs are extensive at the end-of-life, multiple health clinicians working collectively is essential to accomplish the most optimal outcomes for the patient.
  • Collaboration and Communication Between Hospice and Other Care Providers:  Most advanced cancer patients either change locations for care or are admitted to a hospital near the end-of-life, and therefore, effective communication between all involved providers is imperative. Despite consistently improving electronic medical records, the challenge still persists for all clinical teams to be aware of the communication that each care provider has with the patient and their family.

Support for Caregivers

A key aspect of hospice care is the support provided to caregivers, and although research on the topic is limited, evidence suggests that the most effective support for caregivers results in: 

  • Need for information and education being better met
  • Decreased rates of depression 
  • Improved ability to move forward with their own life after the death of their loved one

 In conclusion, the authors state, “Hospice provides patients with the potential for a better quality of life, improved symptom control, and more time away from inpatient care.” Furthermore, since most of the care for advanced cancer patients becomes the responsibility of caregivers, any additional support provided to them while acting in the caregiver role will likely be of significant advantage.


Currow, D. C., Agar, M. R., & Phillips, J. L. (2020). Role of hospice care at the end of life for people with cancer. Journal of Clinical Oncology, 38(9), 937-943.


What are best practices for terminally ill patients who frequent the emergency department? What do patients, families, hospitals and payers want? What is your role? What is the role of hospice?

The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that was developed by the Centers for Medicare & Medicaid Services (CMS) for a reason. Consider the fact that one third of Medicare patients are readmitted within 90 days, and about 20% of Medicare patients are readmitted within 30 days. At Precious Hospice, we can admit patients whose status are appropriate for hospice directly from the emergency department.

Partnering with Precious to Achieve Key Goals

When a hospital partners with Precious, patients with end-of-life needs get the appropriate care, and the hospital can achieve the following objectives: 

  • Reduced ED overcrowding, readmissions and observation periods
  • Improved ED throughput and bed cycling
  • Seamless transitions to post-acute care
  • Improved family-satisfaction metrics

Hospitals are reprimanded for decreased “core measure” quality outcomes and reduced patient/family satisfaction scores.  Furthermore, seriously ill patients do not want to readmit. When surveyed, their preferences and main areas of concern include pain and symptom management, improvement of their relationships with family rather than an increased burden on their loved ones, not lengthening the dying process, and the development and maintenance of a sense of control.  Unfortunately, readmissions are often due to a lack of planning regarding discharge or inadequate community-based or outpatient care, in addition to severely progressive illness.  Patients who are readmitted typically do not have follow-up plans, and oftentimes are not able to voice their diagnosis or medications. Once these types of situations are identified, however, such issues are easy to mitigate.

Indicators that a Patient Might be Eligible for Hospice Care:

  • Frequent readmissions to the emergency department, hospital or intensive care unit
  • Ongoing symptoms continue regardless of suitable, quality treatment
  • Decline of functional abilities
  • Decrease and/or consistent declining of renal function
  • The utilization of inotropes
  • Goals of the patient are centered in their quality of life
  • Response to the question: “Would you be surprised if this patient died in the next 6–12 months?” is NO

When a patient is referred to hospice care as soon as it is fit, patients are able to receive the clinical and psychosocial care needed to control their pain and symptoms, and ultimately improve their quality of life. The interdisciplinary team provides care in the comfort of the patient’s home, and continuous care is provided when medically necessary, keeping the patient from having to go to the hospital.


Strong indicators that your patient could benefit from hospice care are an increased use of emergency department and hospital services, as well as increased burden of symptoms along with decreased overall function.   A way to evaluate this is to use your best judgment to answer the following question:

“Would I be surprised if in the next six months this patient was no longer with us?”

Your answer to the above question will further determine the appropriateness of hospice services for the given patient.

Pressure on Emergency Department (ED) Providers 

Emergency Department providers ideally should feel empowered and honored to implement treatment options for patients that they have recognized as near the end of life.  However, quality metrics such as ED throughput, hospital readmissions and others are placing a tremendous amount of stress and pressure on ED practitioners, as well as the acute care system, to provide quick, efficient, and high quality care to their patients.

As people live longer and medical technology advances, EDs are seeing elderly patients with numerous, advanced, chronic illnesses that progress simultaneously, through the top treatments—until they don’t. The ED staff is then faced with uncontrolled pain, dyspnea, delirium and functional decline that are results from conditions like heart failure, COPD, vascular disease or any combination thereof progressing.  Dementia furthermore makes the situation more complex, especially if the goals of care and advance directives have yet to be conveyed. The patient becomes an ED frequent flyer, leading to difficulties with wait times, throughput, observation utilization, and boarding.

How to Offer Our Patients a Better Life

By determining the frequent flyer patients early in the ED and hospital cycles, and moreover, punctually referring them to hospice care, we can offer them better lives. They can be at home, wherever it is that they call home, and an interdisciplinary team will bring all the necessary clinical services to them.  With the elimination of panicked emergency calls, the quality of life improves. Their families receive support that they need, ED teams are able to focus on emergent care, and we are able to begin the process of breaking the cycle.


Is it possible to have your seriously or terminally ill patients live and die at home? Absolutely, and studies show that they receive more appropriate, and much less costly care that meets their needs and preferences near the end of life.

This can be largely credited to the expertise that a hospice provider possesses with regard to end-of-life care, where they are able to address pain and other symptom management while also tending to the spiritual and social-emotional needs of patients and families. 

Hospice Provides Education to Family Caregivers

In addition to supporting the patient and their family with high quality, professional care, hospice providers must also provide education to family caregivers, who often provide the majority of their loved one’s care.  Effective communication is essential. The interdisciplinary team and the family must concur on the goals of patient care so that everyone is on the same page.  The interdisciplinary team is present in the home and are able to see the layout, the areas the patient most often uses, and what tasks will fall on one or several of the family caregivers. The team will monitor the status of care for anything that might create a threat of harm to the patient.

Family homes are not typically designed to provide healthcare, and furthermore, caregivers may vary in number and ability, which also poses a challenge.  Each person involved must effectively communicate their questions and concerns to ensure the safety of the patient as in situations of slip-and-fall hazards or moving the patient safely, for example. Furthermore, when a family visitor offers to assist, the paradigm and expectations are already in place and allows for less of a chance for misunderstanding or to make a mistake that can lead to an injury.

Hospice Educated Families about Infection Control

When working with families and caregivers, an important aspect that is discussed is infectious disease.  Below are some of the infection control guidelines we expect caregivers to follow:

  1. Maintain good personal hygiene
  • Wash your body frequently
  • Wash your hair at least twice a week
  • Brush your teeth and rinse your mouth after each meal
  • Trim your fingernails and toenails weekly
  • Wear clean and laundered clothes
  • Change dirty clothing and bedding anytime you notice any soiling
  1. Wash your hands thoroughly and frequently
  • Before preparing, eating or serving food
  • After using the restroom, having contact with your own or another’s body fluids, and blowing or wiping your nose

       Best hand washing procedure:

  1. Wet your hands with plenty of soap and warm water
  2. Lather soap over your hands and wrists
  3. Rub the palm of one hand over the back of the other, and rub them together several times, then repeat with the other hand
  4. Interlace your fingers on both hands and rub them back and forth
  5. Clean under your fingernails with a nail-brush or an orange stick
  6. Rinse your hands thoroughly under warm running water
  7. Thoroughly dry your hands and wrists 
  1. Clean your household thoroughly
  • Avoid any household clutter
  • Thoroughly ventilate your home with fresh air
  • Clean kitchen counters with a scouring powder
  • Dust and vacuum at least weekly
  • Mop the kitchen and bathroom floors at least weekly and anytime spills occur
  • Clean inside the refrigerator with soap and water weekly 
  • Add a teaspoon of bleach to each quart of water used for flower vases
  • Wear gloves when cleaning any animal areas (i.e. birdcages, litter boxes, aquariums, etc.)
  1. Clean contaminated household and medical equipment thoroughly
  • Clean medical equipment as instructed by your interdisciplinary team
  • Clean soap dishes, denture cups, etc., weekly
  • Do not use the same sponges or cloths to clean the bathroom and kitchen
  • Do not pour mop water into the kitchen sink
  • Do not clean sponges or cloths in the kitchen sink
  • Disinfect mops and sponges weekly by soaking in one part bleach to nine parts water for 5 minutes
  1. Decrease your exposure to people with infectious diseases
  • Avoid crowds as much as possible
  • Avoid people who have been recently vaccinated
  • Do not share food or drink with others


Dying is a natural process accompanied by declines in function, including neurocognitive, cardiovascular, respiratory, and muscular function.  This process was examined by researchers with regard to cancer patients, and their findings are outlined in this article.

The process of dying varies greatly, and can last up to several weeks in some cases. Actively dying or forthcoming death constitutes the last week of life, and has distinctive clinical signs that are detailed in this article.

The expression of clinical signs differs significantly among patients, but the more of these clinical signs that are shown within an individual, the more likely death is near.

Signs of Active Dying

The determination of a patient transitioning to imminent death is important, so that clinicians can help educate patients and families about the natural dying process.  Furthermore, this helps to inform their necessary decision-making as well as prepare the patient and family for death as much as possible.

Additionally, the care individualized plan is to be updated in order to reflect any changes in the patient’s status, and should include any necessary clinical visits. Please note that a higher level of care may be necessary in specific circumstances of crisis, or symptoms that are not being controlled by initial treatments.

The chart below shows median times that were identified in a study with cancer patients but can be generalized to other causes of death (i.e. heart disease, advanced lung disease, sepsis, and dementia). The following list is not exhaustive but includes some of the more common symptoms.

Days Before Death Clinical Signs
7+ Peripheral edema, delirium, dysphagia of solids, decreased speech, cool/cold extremities
4-6 Abnormal vitals, decreased level of consciousness, dysphagia of liquids
2-3 PPS 20% or less, peripheral cyanosis, decreased response to visual stimuli, drooping of the nasolabial fold, hyperextension of the neck, Cheyne-Stokes breathing, nonreactive pupils, decreased response to verbal stimuli
Less than 2 Death rattle, apnea, respiration with mandibular movement, decreased urine output, pulselessness of radial artery, inability to close eyelids, grunting of vocal cords, fever

Link Between Clinical Signs of Dying and Impending Death

There is a direct relationship between the amount of clinical signs of dying and death:

  • Patients with 2 clinical signs of dying had a 40% chance of dying
  • Patients with 8 clinical signs of dying had more than a 80% chance of dying

The research showed that the more existing clinical signs of death there are, there is a need for an update to the care plan which should include the appropriate interdisciplinary visits.  Ultimately, the process of a natural death results in clinical signs of dying where the more signs that are present increases the likelihood of death.

Involvement of Hospice Interdisciplinary Teams During Clinical Signs of Dying

When clinical signs of dying arise, the hospice interdisciplinary team commences an update to the care plan that will include:

  • Updating the appropriate interdisciplinary team visits
  • Education on the dying process for the patient and family
  • Adjustments to or implementation of medications
  • Ensure that the appropriate medical equipment is in place 

Below, the hospice team roles are described, as they each provide assistance and support in ways that are specific to their discipline and training.

Nurse/nurse practitioner/physician:

  • Discussion regarding the cessation of non-advantageous or troublesome treatments
  • Assure medications and necessary equipment are available to manage symptoms
  • Provide education to the family on utilization of equipment, and explain physiologic changes they may be able to recognize that are associated with the dying process

Social worker/spiritual care coordinator/chaplain:

  • Assist patients and families with exploring and expressing their feelings and navigating their relationships
  • Actively participate in the review of life, including the act of searching for meaningful contributions
  • Facilitate life closure, including forgiveness, addressing regrets, being able to say goodbye, and trying to find acceptance with regard to ongoing losses and death overall

Hospice aides/CNAs are responsible for recognizing the clinical signs of death to then communicate them to the rest of the interdisciplinary team, as well as supporting the patient and family through the dying process in any way they can.


Hui, D., Santos, R., Chisholm, G., Bansal, S., Souza Crovador, C., & Bruera, E. (2015). Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study. American Cancer Society Journals, 121 (6), 960-67.

Hui, D., Santos, R., Chisholm, G., Bansal, S., Buosi Silva, T., Kilgore, K., Souza Crovador, C., Yu, X., Swartz, M. D., Perez-Cruz, P. E., Almeida Leite, R., Salete de Angelis Nascimiento, M., Reddy, S., Seriaco, F., Yennu, S., Paiva, C. E., Dev, R., Hall, S., Fajardo, J., & Bruera, E. (2014). Clinical signs of impending death in cancer patients. The Oncologist, 19(6), 681-87. 10.1634/theoncologist.2013-0457


Help During a Difficult Time
Hospice care is designed to provide a comprehensive selection of services in order to help patients and families through an extremely difficult time.

Precious Hospice provides coordinated care, and support to patients and their families with a range of options that corresponds to their specific needs. Determined by an individualized care plan, hospice care often begins with the interdisciplinary team providing routine home care, but there are a variety of options available.

The goal is to provide patients and their families with options about how their care is administered, while taking into consideration what their goals of care are and the level support they desire, including clinical, social and emotional support from the interdisciplinary team.

While home hospice is a specialized type of care that focuses exclusively on providing comfort and support for people who are facing a life-limiting illness in the patient’s own home, it isn’t about just seeing to the physical needs of the patient. This type of care is comprehensive, and meant to support the patients and their families.

Precious Hospice offers the following services:

  • Assessing and treating symptoms by a highly trained specialist
  • Integrating the family’s goals and principles into the patient’s individualized care plan
  • Mobilizing healthcare resources to ensure continuity of care
  • Guiding patients through the various care settings (e.g. hospital, nursing home, patient’s home, etc.)
  • Medical care from physicians
  • Pain and symptom management from nurses
  • Emotional need management for both the patient and family from Licensed Social Worker
  • Daily living and safety support provided by Certified Nursing Assistants
  • Religious services and spiritual guidance provided by Spiritual Care Coordinator and/or Chaplain

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Precious Hospice partners with patients, families and caregivers to lovingly provide skilled care to the terminally ill. Our multi-disciplinary team is committed to patient pain and symptom management, and the emotional, spiritual and social support for patient and family.

Contact Us

(470) 878-5051
(404) 891-0173
105 Habersham Drive, Suite D
Fayetteville, GA 30214
808 South Michigan Ave.
Chicago, IL 60605
5241 Fountain Drive, Suites A-B
Crown Point, IN 46307

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