Overview

Caution

Warning

There are both county-to-county and state-to-state variability in laws and policies regarding death pronouncement at home. When in doubt, check with your county coroner’s office.

 

Take-Home Points
While most Americans would like to die at home, most die in institutions due to a chronic illness where death was the expected outcome.
Hospice admission criteria relate to:

  • Prognosis (< 6 months if the disease takes its natural course).
  • Goals of care (Primarily oriented toward quality of life, not prolongation of life, symptom control as opposed to curative treatment).
  • Support at home (Hospices may refuse to admit patients with inadequate home support, i.e., a patient who has no designated primary caregiver).
Most physicians dramatically overestimate life expectancy for dying patients, resulting in delayed referrals for hospice.
Home hospice offers substantial advantages in terms of:

  • Improved symptom management.
  • Practical and emotional support for families.
  • Durable medical equipment to make home care feasible e.g. oxygen, hospital bed etc.
  • Hospice nurse available by phone and for in home visits as needed 24 hours a day
  • Hospice nurse comes to home at time of death to assist family
Dying peacefully at home — without being whisked away by paramedics while resuscitation is attempted — is difficult to do without the assistance of a home hospice program.

  • In the absence of a California Medical Agency (CMA) Do-Not-Resuscitate (DNR) form, nothing but obvious death (rigor mortis) will prevent a paramedic called via 911 from attempting resuscitation.
  • If patients who desire a DNR status are without a CMA DNR form readily available, they are de factofull code patients as far as county paramedics are concerned.
  • It is to be remembered that the paramedics report to the local ER physician. Thus even the presence of a medical doctor at the scene of the code will not prevent the paramedics from attempting resuscitation of a terminally ill patient who does not have a written advance directive and a CMA DNR form.
  • CMA DNR forms should be readily available in all clinics and on all clinical wards.
Each state has unique systems to document preferences for care and resuscitation at the end-of-life.
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