Nursing Home is pressuring my mother-in-law to enter hospice

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Nursing Home is pressuring my mother-in-law to enter hospice

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I am her Health Care Surrogate but as they won't declare her incompetent it has not come into effect. I believe the home's intent is to prevent me from making the decision regarding hospice and instead to pressure her to enter it in various ways. This allows them to say "we are doing the right thing and following the patient's wishes" and to cast me as a family member who simply refuses to let go. They are asking her almost daily, as far as I can tell, if she wants to enter hospice. I live out of state and am not present (neither is any other family member). She is very weak and has bad days where she expresses a desire to die, she has come to view hospice as a "way out".

I am not anti-hospice and expect her to enter it in the near future, but want that to be my decision, not the home's (even if it's portrayed as hers). One concern I have is that once the hospice team takes control of her care, they will be who decides if she goes to the hospital when she has a problem. Obviously, they are incentivized against it and I do not want to be arguing with them about whether or not she goes in.

I do not know if the home has a financial arrangement with the hospice care company; I believe they simply think it will be easier on them if she is in hospice as they won't be caring for her as much and won't have to be sending her to the hospital as often.

Apart from applying for guardianship, which could be complicated and expensive, does anyone have any other suggestions on how to deal with this situation?

Care Decisions Health Care Directives Hospice Skilled Nursing Facility

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Doctor needs to provide justification on why she shone discharged to hospice. Mom needs to designate a medical POA ASAP. Pick the hospice company yourself (or medical POA does this).

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I think you are sounding supremely paranoid about hospice. I also think you have no experience with hospice.

A doctor has to recommend it for her.

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Sorry Bulldog, I would disagree with your statement. My father has been in an AL facility for the last two and a half years. I can’t tell you the number of times I have been phoned, waylaid, tutored, nor the number of hospice business cards found in my dad’s apartment. I have no problem with hospice, my mother entered hospice for 60 days before she passed *in a different facility* and that one ALSO pushed hospice - but they were very upset when I chose a hospice that was not one they recommended to me. So, in my experience I would say that yes, there is a ‘push’ for hospice in many facilities. Don’t know if it is kickbacks, or an avenue to off-load staff chores and responsibilities. Regardless, to family members, it feels unseemly.

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In my experience hospice is not a “way out” but a way through. Your mother-in-law will not qualify for hospice unless a physician believes she has six months or fewer to live. It is not in their interest to hasten death but there is generally an understanding that the client will not be rushed to the hospital as the goal is providing comfort care in a person‘s last days. I don’t really understand your comment that they are incentivized against it. When someone goes to the hospital on hospice they are typically discharged and often readmitted when they return home.

I agree that you should do some research and choose the hospice you
prefer—this might be a way to feel less manipulated and more a part of the best possible outcome since you anticipate her entering hospice in the near future.

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Sorry Midwest - I would disagree with your statement. My father has been in an AL facility for the last two and a half years. I can’t tell you the number of times I have been phoned, waylaid, tutored, nor the number of hospice business cards found in my dad’s apartment. I have no problem with hospice, my mother entered hospice for 60 days before she passed *in a different facility* and that one ALSO pushed hospice - but they were very upset when I chose a hospice that was not one they recommended to me. So, in my experience I would say that yes, there is a ‘push’ for hospice in many facilities. Don’t know if it is kickbacks, or an avenue to off-load staff chores and responsibilities. Regardless, to family members, it feels unseemly.

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Your MIL is competent to make her own decisions based on what you have written. All the rest is up to her and her medical team unless she decides to make you her active POA for medical at this point or you file for guardianship which if she is competent and in care, I’m not sure on what grounds you would win.
Consider, aside from what suffering she must deal with, that she must have a terminal diagnosis to qualify for hospice, that she is in a nursing home alone and wants “a way out”. Wouldn’t you?

edited to say. Hospice is not a way out. It’s a more compassionate level of care but one can’t blame MIL for wishing it were.

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If you are not her MPoA and she doesn't have a guardian nor seem to be cognitively impaired then the facility seems to be doing the right thing. Maybe you are coming across to the facility as "adversarial" and this is why they are not actively looping you in? I'm sorry for this distressing situation. Is there any way you can travel to visit your Mom if she's progressed enough to have hospice recommended to her? They recommend it for good reasons...

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I think the OP is coming across as not being there at all for MIL while she expresses a desire to die constantly. What SHOULD they do for the poor woman, OP????? Good grief.

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Why would you want your MIL to have to keep going to the hospital to be poked and prodded and then sent back to the facility?
Wouldn't you rather that she just be kept comfortable and pain free so she can die in peace?
It sounds like your MIL has already made her decision as she's ready to die, so I'm not clear as to what your hesitation is, unless you are not to the place where you're ready to let her go yet. And if that's the case, that is your issue not your MIL's. Please don't let her suffer needlessly.
Perhaps you need to do some more research about hospice to find out exactly what to expect. They are not the enemy, but are there to help the transition from this world to the next as smooth as possible.

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Hospice does not exist just to get more money from care facilities.

Why does it have to be on YOUR terms when she enters hospice? If MIL is mentally sound, it’s her choice.

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Why do you think she is being pressured instead of wishing to have comfort care instead of life-prolonging care? I think someone in the family needs to visit her asap to understand her condition and her wishes for end of life care, DNR, Do Not Hospitalize orders, etc.

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The Facility is not preventing you from anything. Seems MIL is capable of making her own decisions so your Heathcare proxy is not invoked. She can tell them what she wants and does not want. A doctor has to write and order for Hospice. Ask to talk to the facility doctor and see what he suggests.

Hospice is end of life. The facility gains nothing in having them come in. Medicare pays for the service not the room and board. She will be kept comfortable. Morphine for pain and trouble breathing. Anxiety meds to keep her calm. A doctor does not usually recommend hospice unless its needed. It also means, no more hospital visits.

My Mom was in LTC. She was 89 with Dementia. I was told the doctor recommended her getting evaluated for her swallowing problem. This is first sign of the body shutting down. She had already refused to get out of bed and closed her eyes not opening them again. I was not going to allow them to poke and prod her. I said time for Hospice. My RN daughter came and examined her and said it was time. I went to visit her with my disabled nephew who had lived with her and left at 1:30pm, she passed peacefully at 1:50 pm. I have never regretted my decision.

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I so appreciate your comment. Well stated and spot on Thanks for being a great advocate.

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You deal with it by allowing MIL to make her own decisions.

Hospice provides another set of eyes on MIL and a level of care that she needs now. Don't prevent this help for MIL out of some misinformed ideas that you have. At the very least, you could call the hospice team and discuss your concerns.

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Our family has only had bad experiences with three different hospice companies.
Contrary to what most people believe, many patients are placed on hospice for free equipment and free services. I was told this by more than one hospice worker.
My parents were “qualified” for hospice and not at end of life. Three different hospice companies qualified my parents on three different diagnosis. My mother didn’t even qualify with the first hospice company until a different nurse came on board and simply signed her on. I am a retired licensed social worker and know what hospice used to be. It’s changed. You are wise to be cautious.

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I've been a hospice volunteer for 20 years, and this "new" hospice is NOT as Medicare envisioned it in the 1980s. It is a money-making scheme perpetrated by the "for-profit" hospices run by corporations and venture capitalists. Hospices have cleverly found a way to include dementia patients in their hospice services. Sure, there are many dementia patients within six months of death. However, the VAST MAJORITY in my experience are not within five years of death, let alone the required six months. This allows these hospice companies to bill Medicare for patients who don't need any real hospice services. Many live in Assisted Living or memory care facilities, where the staff at the facility care for them. The hospices often withhold meds and services to save money. The cap for each hospice is $33,000 per patient, per year. If you do the math, this adds up to a lot of money for a brief visit from hospice staff a month. It is fraud, pure and simple. Not all have this "new" business model, but many do, as is evidenced by your family's experience.

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Ooh that's a tuffy, but not. If she hasn't been declared incompetent, she is evaluated to have capacity and understanding to make o wn decisions. If the family IS NOT as present, you may not be in touch with her feelings that may lead her to wanting HOSPICE. " as a way out" , as you have said. However, I too have my own ," pushbacks" regarding HOSPICE in some cases and I am a licensed Social Worker with recent experience with this in a personal manner. Continue to be an advocate and ask questions , but RESPECT her decision

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Wow, the activity on this thread is suddenly very suspicious.

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People sure do come out of the woodwork when the dreaded hospice word is mentioned, don't they? 🙄

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My mom was on hospice in my home with a not for profit hospice agency...I just trusted this option more than a for profit agency. A nursing home may push for hospice as some of their staff's responsibility would be replaced by hospice staff. I suppose if the hospice is affiliated with the Nursing Home this may benefit them also. If they really think your MIL needs hospice, can you hire an agency you find?

The last time my mom went to the hospital (she was having shortness of breath) she had told me she didn't want to go. When the SOB continued, I told her I was concerned and asked if she would go to the hospital for me. She agreed...and of course the problem resolved by the time she got there. If she was already on hospice, there would have been medication available to help with the SOB and prevent the trip to the hospital that she didn't want.

At age 96 with daily pain, my mom was ready to go. She was only on hospice for 2 weeks before she passed. I feel we missed out on help and services (an aide and social worker) that would have helped both of us through this difficult period. Can you or your spouse visit her to see what condition she is in and if she is sleeping more and not eating? Does she feels that trips to the hospital are just prolonging the inevitable and having her suffer with a poor quality of life?

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Tho I have some mishivings about involving hospice when one is not able to monitor the care, I agree. We missed out on services that would have helped us all but waited too long.

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If mother is constantly expressing a desire to die, then the SNF is listening to her and asking if she'd like hospice services. Hospice is not a "way out".......just a way out of PAIN and suffering at end of life. These hospice comments get exhausting to read after awhile. What killed my parents was old age and disease, not hospice.

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Part of entering hospice is an agreement the patient will not go to the hospital. This was a concern I had and did not contract with hospice for that reason. We had them for home care with my dad and they were great. But in a facility, I have concerns if you are not local to monitor and supervise, if you have health care surrogate power, their conduct. I asked mom’s home health care nurse if we should involve hospice with my 98 yo mom with moderate dementia. He could not answer quickly enough—no. So there is a wide range of services I think, some of which appear to be drugging them up when it may not be beneficial to the patient.
Best of luck!

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If your MIL has a chronic condition and has medical emergencies often, then she should go into Hospice Care. I am sorry about the stressful situation, but it's not with bad intentions that her personal care home is encouraging this. It is very detrimental for your loved one to have to constantly be taken by ambulance to the hospital. Both Medicare and Medicaid help pay for Hospice Care. It's not a negative. Your mother in law can still live on while in Hospice.

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1) No one can be forced onto hospice against her/his will if s/he is mentally competent and refuses it, The same for a person w/a health care POA who decides the health care s/he receives.

2) Check several hospices before choosing one. Ask for recommendations from the loved ones of former clients or your clergy (if you are a member or regular attender of a churchm, synagogue, mosque, or temple)

3) Even once on hospice, it's possible to take someone off to use a hospital or keep an appointment made prior to starting hospice. My late husband's hospice chaplain told me this. Take them off for a day (or more) and then subsequently re-enroll them. I did this for a day to allow my late husband to attend a follow-up appointment made before he started hospice. Then I re-enrolled him the next day;

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Your family is wise to be cautious.

Call the supervisor of the home and tell she or he that the family will make the decision and you don't want your mother to get this pressure.

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concerned8: Prayers forthcoming.

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What in the world leads you to think hospice is "incentivized" to not send your mother to the hospital and have her get care for things that can be treated in Hospice (comfort care things)? When the patient DIES hospice loses. You get that, right? The customer is GONE, just like that.

Your mother has expressed a wish to go now. Please honor that and get her into hospice. This isn't your decision or theirs. This is your mother's decision.

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The Memory Care facility where my mother lives recommended hospice in February of this year, not because Mom's demise is imminent, but because of her declining condition. The last few months I have been so grateful for the wonderful resources and support hospice has provided. Not only do they send someone twice a week to shower her in addition to the bathing the facility gives her, but the staff also does special things like paint her fingernails, play oldies tunes for her, blow dry and style her hair, etc. She also receives two nurse visits a week, a local pastor visits her and plays his guitar, and a social worker visits to comfort her or listen to my concerns if I have any. Hospice always texts or calls me after each visit and even the pastor calls me and fills me in on his visits with her. I am able to contact them any time I have a question. They have been an advocate to both my mother and me.

Hospice has also provided a special hospital bed, a padded wheelchair, a shower chair, a raised potty seat, all at no charge to us, and even provides the adult briefs, sanitary gloves and wipes, and pays for any medication consistent with Mom's diagnosis. They have also met with me and the facility staff and been a part of the care plan for my mother going forward. Medicare pays for these services and the way it was explained to me, it is something that we are eligible for after working so many years and paying into FICA taxes that fund Medicare.

I was feeling alone and almost desperate before hospice stepped in to help. I cannot say enough positive things about the hospice care my mother is receiving and I thank God every day for their services!

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Hospice painted my mothers nails and she loved it so much I went to the dollar store and bought her about 10 bottles of polish. It became something special for us. I'd go to the thrift store and get her colorful shirts to match her polish. Thanks for the fond memories Lee188! It also helps hide the food she would get trapped under her nails, lol.

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My 96-year-old Mother is in a hospice program at her assisted living facility, which is called VITAS, covered by Medicare. It is an extra pair of hands and eyes taking care of my Mom, who, due to a stroke, cannot walk or use one arm, so she needs 24-hour care. The program supplies all necessities to care for her, and also has its own nursing aids and social workers checking on her daily and weekly. Hospice is not just for the dying; it is also for level 3 or 4 residents at nursing facilities to make their daily living comfortable, and the family has a social worker to get all info and updates daily if you want.. It is an amazing program, highly recommended to all.

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When the patient goes into Hospice care, the facility turns the care over to them. They distribute medications or they work with the facility as to what medications to give the patient. Yes, hospice takes control of the care. No, the facility does not get a kick back, that I know of, for turning the patient over to hospice. Although it frees up their caregivers to assist other patients. (and they get paid for using their bed, by you)

Because you are out of town, it is easier for them to persuade your mother-in-law to make a decision. Are you the POA for her medical decisions? Who is responsible for making health decisions for her? If there is not a person set up for those decisions, then I would definitely contact an Elder Law Attorney. Seek out someone that understands Patient Advocacy. DO NOT ALLOW the facility to take control away from your or her family.

I fought with hospice here in Florida for my father. Hospice nurses were relentless. They insisted on giving my father morphine, (for your understanding, morphine slows down the body with the intentions to assist in their death. If your mother-in-law is in pain then it is understandable, but if she is not, please do not allow them to give her morphine), we found another medication to help relax him in his final days. I did have a couple of nurses finally see things my way and work with my wishes for the care of my father.

Hospice is a great organization in some areas. Not so great here in Florida. We had an awesome memory care facility that allowed the caregivers (that cared/loved my father) to assist us during the last 3 wks of my fathers' life. They came in every 30 mins during the night to check on him and every 2 hours during the day even when we were there. (They wanted to check on us as well) Hospice was to help us with caregivers, of which did NOT happen. Nurses and Social Workers came in regularly.

I hope this helps.

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I know family is all out of state, but seems like it’s time to schedule an in person meeting w/ nursing home & MIL since she’s still considered competent & see what the situation really is. Find out why they feel she should go on hospice, does your MIL really want to, & see what her condition is really like.
I say this because it’s hard to see the whole picture without being there in person. It may be that your MIL is worse than you can tell over the phone. Or you could be right, but someone going in person to meet with all involved is the best way to find out.
if hospice is decided on, do research on companies so that you as a family with your MIl can make a good choice. We had 1 bad experience with a company, but have had 3 really good experiences with companies. 2 were long term & 1 was for only 2 weeks. Yes, it can mean no more hospital runs , but what are the hospital runs for? Is it for uti’s, more serious things? Hospice will give meds for the uti’s etc. They don’t only give pain & sedation medications. Are the hospital runs making her life better? I have sat with my dad at least 5 days a week for 8 months at the nursing home listening & watching people suffer & get weaker & weaker, have no joy anymore, no one visiting & families still fighting against hospice, having them sent to the hospital with this & that. Most of the time the person comes back more tired & weaker. I’m not saying that’s you, but without actually seeing what your loved one goes through every day, you may not be seeing something the nursing home sees.
My MIL was on hospice for 5 years. She was bedfast with several kinds of arthritis. Her bones just all locked up where she could no longer move her legs & body much. Hospice was a wonderful help. With all of our good experiences with different family members, hospice was an extra set of eyes on our loved one & eyes in the facility. We got 3 updates a week between the nurse visit & 2 aide/shower visits. The one we are using currently for my dad watched the facility closely. They make notes on things they see that are good & not so good & have confronted the facility on several things. They have been such a great help! And it’s several other people making contact with your loved one with an in person visit since your family can’t be there.
My comments aren’t a judgment, just a reminder to make sure you have the whole picture and to keep your MIL quality of life & comfort in mind.

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There are reasons our loved ones have Health Care Surrogates, Patient Advocates or POA's. As they progress in age or illness it is harder for them to make decisions regarding their own health. We are here to fulfill their wishes as they progress in life, even regarding their health.

If your MIL is that unhappy, maybe it is time to have a conversation with her as to what her wishes are. It is not the facilities' responsibility to have that conversation. Most importantly, the person that is having the conversation must have not greedy intentions. (That happened in my family and my father was misled in his decision making. He would have been dead 8 years ago instead of passing in Feb 2025, all because of money.)

Facilites (with doctors' recommendation) and/or Doctors are the ones to speak with the patients, family members or representatives of the patients regarding Hospice Care. If the facility is speaking to your MIL, they are not acknowledging you're Health Care Surrogacy position. If it is not legally documented, then your MIL can make that decision on her own.

I would recommend you get advice from an Elder Law Attorney or a Patient Advocate to get advice on what should be done.

Hospice can be difficult. The nurses (most of them) are relentless. (I found a couple that would work with me) They are trained to give morphine to all patients. They will tell you it is for pain, although not all patients are in pain during their last days. Morphine slows down the organs and assists in a quicker death. (everyone here can disagree, but it is true) There is a couple of other drugs that will calm down the body's muscles during the last days to help the patient to be more comfortable.

I have not had a great experience with hospice here in Florida. The Social Workers were great. No caregiving support, although they tell you they will provide it.

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That " medication comfort piece" is arguably assisted death and I totally agree with your perception FACTUAL

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A doctor has to approve hospice treatment. My husband (with dementia, 93) has entered hospice and the care has been remarkable. He has a Hoyer hoist which helps him to get in and out of bed, a special bed that can be raised or lowered, a chaplain twice a month, a social worker once a month, an aide who helps him bathe each morning, and a nurse overseeing his case. This is in addition to the amazing staff at Churchill Place Memory Care in Glen Ellyn. You do have a choice in hiring a hospice company -- some are better than others. Perhaps in the old days, hospice meant over medication. Now it is set up to provide comfort to an individual.

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As her health care surrogate it's your choice but you have to honor her wishes,too! It's your position to get her the care she needs, regardless of your emotions. It's all about her!! Facilities usually recommend hospice when they see someone failing and know that they can no longer make them comfortable. You never mentioned age or health problems, why would they be sending her to the hospital? If she is under hospice care, you can send her to the hospital but the bill would be yours. I was told by hospice to keep up with mom's health premiums, just incase it went either way, better or worse. Luckily, I had her sent to the hospital when she got covid19,bills were paid by her medical insurance. The only drawback with hospice is usually DNR, do not recessitate. But as being elderly, bone breakage is going to happen if they try and if they bring them back, oh the pain as they can't mend like in their youth. I think you need to evaluate your position on the commitment you made as being her health director. Is this good for the patient? It's not about you, sorry.

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Hospice is not what it used to be and all hospice companies are not the same.
A good hospice company will make your mil feel spoiled.
What medicines and treatments would be cancelled if she were on hospice? How would this affect her care?
Our brother was on hospice and a “full code”
If he needed the hospital for any reason, he could come off hospice, be treated, go back on hospice. There are good reasons to need a hospital such as bleeding and infection unrelated to the hospice diagnosis.
It costs nothing to talk to one or several hospices and see if one is a good fit for your mil.

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You can escalate with their patient coordinator and tell them you feel she’s being pressured. You should tell them you want to be on the phone whenever they approach her with any care questions. While you’re on the phone with her you could also advise her to tell them they should talk to you for care questions .
regarding the healthcare proxy, what’s the language in the document. Maybe you can have another licensed physician not y the facility be called in and determine incompetence. Perhaps you can have a new directive drafted that gives you immediate healthcare powers and are not triggered my incompetence per se.
it would be all easier if you’re closer. Any options to engage someone closer?
It is sad to say but these facilities see people as dollar signs. There are even incentives to not send ppl to the hospital from long term care facilities which is why sometime you hear stories of patients not getting the care they need. Wish you all the best.

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Nursing Home is pressuring my mother-in-law to enter hospice

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