Some of you may see this differently—and that's okay. I'm simply offering another way to think about this subject.
I don't believe that choosing to remain "full code" aligns with the purpose of hospice care. When that is the goal, palliative care may be the more appropriate path.
Having hospice teams perform CPR goes against what hospice is designed to do—guide, educate, and support a natural dying process.
Palliative care supports people receiving treatments, even though treatments may be not be life prolonging.
Both hospice and palliative care support the person where they are in their life journey. Each has its place in the medical arena. They simply serve different purposes.
Palliative care often accompanies ongoing medical treatment.
Hospice is directed to comfort and support quality of life during the dying process.
No one is required to choose hospice. But when a person does, they are choosing support for a natural death with care that centers on comfort, guidance, and support for both the patient and their caregivers.
Medical care is focused on cure.
Palliative care is for those who are pursuing a cure.
Hospice care is not curative. It is comfort care.
Everything hospice does is meant to support the natural dying process of the patient with comfort. The focus is not on stopping death, but on easing the path toward it with dignity.
Something more...
If you are caring for someone at the end of life, either in palliative or hospice care, you don’t have to figure it out alone. By Your Side provides guidance on what to expect and how to care for your special person.
10 comments
Ashley
Hello,
I am an on-call hospice nurse, and recently, there has been a discussion about what should happen if a patient who is full code dies in the home. There is a bit of a question if, legally, the RN could perform the pronouncement since the patient is a full code and technically CPR should be started. Would you happen to have any guidance for me/us? I am in Massachusetts.
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BK Books replied:
I’m sorry Ashley I do not have an answer for you. Blessings to you in the work you are doing. Barbara
Hello,
I am an on-call hospice nurse, and recently, there has been a discussion about what should happen if a patient who is full code dies in the home. There is a bit of a question if, legally, the RN could perform the pronouncement since the patient is a full code and technically CPR should be started. Would you happen to have any guidance for me/us? I am in Massachusetts.
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BK Books replied:
I’m sorry Ashley I do not have an answer for you. Blessings to you in the work you are doing. Barbara
KB
Just looking for an outside opinion. Going thru end of life with a family member. She will be 95 later this month. I am curious your thoughts. She had been in assisted living for a couple years. Short term memory diminished almost completely. Long-term is ok. Someone providing foot care noticed a spot on her foot. It has been there since she was first there, but last fall it got referred to primary care, who strongly insisted she get it checked. It was a skin cancer. The said it needed to be removed. This was at same time, we were going to switch her to palliative care. The procedure happened, despite family thinking it is not bothering her, it has been there, let’s just leave it at 94 years old. On the way home from the procedure she could not remember why her foot was bandaged anad kept removing it, pulling it and caused it to start bleeding multiple times. Ended up in ER more than once, and admitted back to the hospital. Hospital setting led to confusion really setting in, or exaserbated it. and now is nursing home. It seems to me it was unnecessary to do that kind of a procedure at that point. It just feels like they push procedures and tests on someone who is end stage. She now sleeps majority of time. She just exists and it is hard to visit with her. I do but it is so sad. I say she has a strong constitution but a 95 year old body is wearing out and it feels like extensive efforts to keep her alive. We have said we want her to be comfortable and cared for.
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BK Books replied:
Oh KB, I’m so sorry your person had to be put through the medical procedure. As you pointed out it accomplished nothing and created a level of discomfort and disorientation that needn’t have happened. This is another example of the medical model treating the disease and not the person. My blessings to you both. Barbara
Just looking for an outside opinion. Going thru end of life with a family member. She will be 95 later this month. I am curious your thoughts. She had been in assisted living for a couple years. Short term memory diminished almost completely. Long-term is ok. Someone providing foot care noticed a spot on her foot. It has been there since she was first there, but last fall it got referred to primary care, who strongly insisted she get it checked. It was a skin cancer. The said it needed to be removed. This was at same time, we were going to switch her to palliative care. The procedure happened, despite family thinking it is not bothering her, it has been there, let’s just leave it at 94 years old. On the way home from the procedure she could not remember why her foot was bandaged anad kept removing it, pulling it and caused it to start bleeding multiple times. Ended up in ER more than once, and admitted back to the hospital. Hospital setting led to confusion really setting in, or exaserbated it. and now is nursing home. It seems to me it was unnecessary to do that kind of a procedure at that point. It just feels like they push procedures and tests on someone who is end stage. She now sleeps majority of time. She just exists and it is hard to visit with her. I do but it is so sad. I say she has a strong constitution but a 95 year old body is wearing out and it feels like extensive efforts to keep her alive. We have said we want her to be comfortable and cared for.
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BK Books replied:
Oh KB, I’m so sorry your person had to be put through the medical procedure. As you pointed out it accomplished nothing and created a level of discomfort and disorientation that needn’t have happened. This is another example of the medical model treating the disease and not the person. My blessings to you both. Barbara
Shoshana
I always appreciate the information that you send out. Having worked in Hospice years ago, and Palliative Care just arriving when I left, we always had a DNR status for admission. Maybe, prior to an admission to Hospice, a visit could be made to explain it all more fully.
Thank again! Your posts keep me in “the loop.”
Shoshana
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BK Books replied:
Hi Shoshana, Absolutely, that initial “here is what hospice is about before you come on service” visit is the place to discuss DNR and No Code reasoning. Blessings to you! Barbara
I always appreciate the information that you send out. Having worked in Hospice years ago, and Palliative Care just arriving when I left, we always had a DNR status for admission. Maybe, prior to an admission to Hospice, a visit could be made to explain it all more fully.
Thank again! Your posts keep me in “the loop.”
Shoshana
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BK Books replied:
Hi Shoshana, Absolutely, that initial “here is what hospice is about before you come on service” visit is the place to discuss DNR and No Code reasoning. Blessings to you! Barbara
Roberta Gottlieb
And…..families considering retaining “Full code” status need education on what that outcome may look like- most often it’s unsuccessful out in the field even in patients without multiple comorbidities or with a terminal diagnosis. And of those who initially survive, they undergo invasive procedures such as intubation, etc and most of those patients will still die within the next 24 hours. So families don’t understand the implications of the “full code” status for their loved one and need the realistic and statistical information I order to make an informed decision.
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BK Books replied:
Roberta, well said. Thank you. Blessings! Barbara
And…..families considering retaining “Full code” status need education on what that outcome may look like- most often it’s unsuccessful out in the field even in patients without multiple comorbidities or with a terminal diagnosis. And of those who initially survive, they undergo invasive procedures such as intubation, etc and most of those patients will still die within the next 24 hours. So families don’t understand the implications of the “full code” status for their loved one and need the realistic and statistical information I order to make an informed decision.
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BK Books replied:
Roberta, well said. Thank you. Blessings! Barbara
Terry McCabe
Appreciating this message, Barbara. What are your thoughts about treatment which alleviates potentially unnecessary suffering while in hospice care? When my mom was receiving hospice care, she developed a UTI which was uncomfortable/painful. There wasn’t consensus among hospice staff regarding antibiotics. Our family felt that treating the uti would keep her comfortable….we all understood it would not prolong her life….but it would have improved the quality of her remaining time. It was a bit unsettling that there wasn’t agreement amongst hospice staff on this. I’m interested in your perspective. Thank you for your ongoing ministry and for sharing your wisdom. You were a blessing to me as a caregiver while my mom was receiving hospice care.
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BK Books replied:
Hi Terry, I am surprised there was debate over treating a UTI. In my mind of course you would treat it. It is a COMFORT measure. It wouldn’t prolong life but certianly make the remaining time better. That is what hospice is about. Helping a person live the best they can while they can. Thank you for mentioning this. Blessings! Barbara
Appreciating this message, Barbara. What are your thoughts about treatment which alleviates potentially unnecessary suffering while in hospice care? When my mom was receiving hospice care, she developed a UTI which was uncomfortable/painful. There wasn’t consensus among hospice staff regarding antibiotics. Our family felt that treating the uti would keep her comfortable….we all understood it would not prolong her life….but it would have improved the quality of her remaining time. It was a bit unsettling that there wasn’t agreement amongst hospice staff on this. I’m interested in your perspective. Thank you for your ongoing ministry and for sharing your wisdom. You were a blessing to me as a caregiver while my mom was receiving hospice care.
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BK Books replied:
Hi Terry, I am surprised there was debate over treating a UTI. In my mind of course you would treat it. It is a COMFORT measure. It wouldn’t prolong life but certianly make the remaining time better. That is what hospice is about. Helping a person live the best they can while they can. Thank you for mentioning this. Blessings! Barbara
Lori Martin
If someone has dementia and non-insulin dependent diabetes, just oral diabetes meds would they still continue those meds while on hospice? Or would that be palliative care only?
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BK Books replied:
Hi Lori, good question. I think you would continue giving the medication. End of life care is about comfort care until death comes. It is not about shortening life. Blessings! Barbara
If someone has dementia and non-insulin dependent diabetes, just oral diabetes meds would they still continue those meds while on hospice? Or would that be palliative care only?
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BK Books replied:
Hi Lori, good question. I think you would continue giving the medication. End of life care is about comfort care until death comes. It is not about shortening life. Blessings! Barbara
Ptarmigan
I agree that Full Code dies not seem to be aligned with hospice. However, Medicare has stated it should not be a barrier to getting onto hospice service. The idea, I think, is that as hospice providers, we can start, or continue, that conversation and surround that patient, and theur family, with resources including someone to ask questions of AND talk about changing from Full Code to DNR. Hospice is, really, the only fully holistic program, by the government, that offers that type of support. If palliative was “hospice lite”, it might be a different story. But its not. So, often, us hospice people are the first people patients can actually talk to, about end of life, without someone saying “oh, mom/dad dont talk like that, you are going to be fine”. And switching from a Full Code to a DNR is a really big decision.
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BK Books replied:
Ptarmigan, I know Medicare has said hospice does CPR if the family wants it and yes, it is hospice’s “job” to educate the patient/family/caregiver about why it is in the best interest of the patient not to do it -— BUT I still disagree. Blessings! Barbara
I agree that Full Code dies not seem to be aligned with hospice. However, Medicare has stated it should not be a barrier to getting onto hospice service. The idea, I think, is that as hospice providers, we can start, or continue, that conversation and surround that patient, and theur family, with resources including someone to ask questions of AND talk about changing from Full Code to DNR. Hospice is, really, the only fully holistic program, by the government, that offers that type of support. If palliative was “hospice lite”, it might be a different story. But its not. So, often, us hospice people are the first people patients can actually talk to, about end of life, without someone saying “oh, mom/dad dont talk like that, you are going to be fine”. And switching from a Full Code to a DNR is a really big decision.
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BK Books replied:
Ptarmigan, I know Medicare has said hospice does CPR if the family wants it and yes, it is hospice’s “job” to educate the patient/family/caregiver about why it is in the best interest of the patient not to do it -— BUT I still disagree. Blessings! Barbara
Kim Orth
This is such an important piece! I agree 1000% with you Barbara, anyone wanted to be a full code should not be considered for hospice. One home health hospice agency I worked for would not admit anyone to hospice without a NO CODE signed. Another allowed FULL CODE patients be admitted to Hospice and then tried to have them change CODE status. I personally feel it is easier and a less of an ethical thing being a NO CODE as an upfront requirement. Thank you as ALWAYS for your expert opinion and advice.
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BK Books replied:
Hi Kim, I agree with you. Blessings! Barbara
This is such an important piece! I agree 1000% with you Barbara, anyone wanted to be a full code should not be considered for hospice. One home health hospice agency I worked for would not admit anyone to hospice without a NO CODE signed. Another allowed FULL CODE patients be admitted to Hospice and then tried to have them change CODE status. I personally feel it is easier and a less of an ethical thing being a NO CODE as an upfront requirement. Thank you as ALWAYS for your expert opinion and advice.
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BK Books replied:
Hi Kim, I agree with you. Blessings! Barbara
Jerry Soucy
Thanks for laying it out so clearly – I agree cpr (and other aggressive life sustaining treatments) aren’t appropriate when the goal for care is a peaceful (normal, expected) death.
CPR etc are appropriate if the goal for care is to beat or cure or keep going no matter what
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BK Books replied:
Hi Jerry, my thoughts exactly. Blessings! Barbara
Thanks for laying it out so clearly – I agree cpr (and other aggressive life sustaining treatments) aren’t appropriate when the goal for care is a peaceful (normal, expected) death.
CPR etc are appropriate if the goal for care is to beat or cure or keep going no matter what
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BK Books replied:
Hi Jerry, my thoughts exactly. Blessings! Barbara
MARIA D'MARCO
Such an important message, Barbara. Dignity, for the person leaving, as well as for those experiencing that loss. Hospice is, to me and in my experiences, the guidance across the blessed bridge, where each person involved can take and give a hand.
Thank you for your continued guidance and superior education in the natural event that is our passage beyond this existence.
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BK Books replied:
Hi Maria, thank you for your sharing. Blessings! Barbara
Such an important message, Barbara. Dignity, for the person leaving, as well as for those experiencing that loss. Hospice is, to me and in my experiences, the guidance across the blessed bridge, where each person involved can take and give a hand.
Thank you for your continued guidance and superior education in the natural event that is our passage beyond this existence.
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BK Books replied:
Hi Maria, thank you for your sharing. Blessings! Barbara