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Deciding Where to Die

Choosing Your Place of Death

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Updated August 25, 2008

Making the decision where to spend the last day’s of life isn’t always easy. Each choice has its pros and cons, and personal preference can sometimes be trumped by practicality.

If you are faced with making this decision and need a little guidance, I encourage you take notes as you read along. For each option you are considering, list the pros and cons for each. Reviewing your notes when you’re done should provide you with some clarity and direction.

At the Hospital

Most people, if given a choice, would choose not to die in a hospital yet nearly one half of all deaths related to chronic, life-limiting illnesses happen there. Some people would actually prefer to spend their last days in a hospital where they feel secure in the skilled care they receive. Other people find hospitals loud, impersonal, intrusive and lacking in privacy. These people would prefer to spend their final days in a more intimate, peaceful setting.

Hospitals are places of advanced technology designed to save lives, extend or prolong lives, and alleviate suffering. Hospitals have physicians, nurses, nurse assistants, lab technicians, pharmacists, respiratory therapists, and so much more, on hand 24 hours a day. The technology and skilled care that a hospital can offer means that symptoms such as pain and breathlessness can be treated aggressively.

However, the advanced technology and the large number of staff in a hospital also make it a busy and loud place to be. Patients are often woken up several times during the night for vital signs and medications, nurses are bustling around between patients and the nurse’s station, monitors and IV poles beep, and alarms sound. The noise and commotion can make the hospital a less-than-perfect place to find peace and rest.

Sometimes patients don’t want the aggressive treatment that hospitals can offer either. Hospitals often administer fluids and medication in an intravenous (IV) line and patients are often hooked up to monitoring devices to monitor their heart or breathing. Oxygen levels may be tested often and oxygen given through a nasal cannula, which is tubing with two small prongs inserted just inside the nostrils, or a face mask. Nutrition may be given through a nasogastric (NG) tube or gastrostomy (G) tube. All the lines and tubing can restrict patients and make them more uncomfortable.

In a Skilled Nursing Faciltiy

Skilled nursing facilities (SNFs), or nursing homes, also offer 24 hour nursing care. They are staffed less than a hospital, however. Nurses and nursing assistants are on-site to give personal care, administer medications and treatments, and provide nourishment. Some SNFs can even provide IV hydration and medications, and tube feedings.

Sometimes the staff at SNFs aren’t skilled, or even comfortable, providing end-of-life care. For this reason, many SNFs allow hospice agencies to come into the facility to provide care to the patient and educate the staff on end-of-life care.

Skilled nursing facilities are very costly and usually aren’t covered by Medicare or private insurance companies for end-of-life care. Long term care insurance covers SNF expenses but most people don’t purchase this type of insurance. Federal and state Medicaid programs cover SNF expenses but most people with any kind of assets won’t qualify for this type of assistance.

In Residential Care Facilities

Residential care facilities include assisted living and board and care facilities. Care in these facilities is delivered in a home-like setting. Care is usually supervised by a nurse but nurses may not always be on-site. Care is usually provided by trained caregivers.

Once again, staff at these facilities aren’t always skilled at or comfortable with providing end-of-life care. Hospice may be brought in to provide expert palliative care.

In an Inpatient Hospice

Inpatient hospices are available in some communities. Inpatient hospice facilities are very similar to skilled nursing facilities; they both provide 24 hour nursing care but care in an inpatient hospice is provided by hospice trained professionals.

Like nursing homes, Medicare and private insurance companies don’t usually cover the cost of inpatient hospice facilities. Fortunately, many inpatient hospices are supported by charity, making the financial burden less than nursing homes. Additionally, the Veteran’s Affairs system provides inpatient hospice services to most U.S. veterans free of charge.

At Home

Home is the place identified by most people as the place they wish to spend their final days. At home, patients can set their own schedules, have the privacy they desire, and be in a familiar and comfortable place. Despite these advantages, only one quarter of deaths actually occur at home. Family isn’t always available 24 hours a day to provide care, and even if they are, they might not be comfortable doing it. Hiring caregivers is costly and not everyone is comfortable having strangers in their home for extended periods of time.

Patients wishing to spend their final days at home often sign up for hospice care. Hospice doesn’t provide 24 hour care, but they offer invaluable support to family and friends who want to provide the care themselves. Hospice agencies can also help patients and families find the right solution for care that fits their needs and budgets.

Making the Right Choice for YOU

If you’ve been taking notes or keeping track of the pros and cons for each option you’re considering, review that list now. Which option has the most pros? Which option has the least cons? Finally, ask yourself what the patient’s wishes are? Are you able to honor their desires?

Keep in mind, as with any medical decision, nothing is set in stone. If you initially choose one location and decide down the road that you’d be better off somewhere else, you can change your mind. Knowing your options and planning in advance can make any decision you make easier to handle.

Sources:

The Medicare Hospice Benefitwww.medicare.gov

D.B. Feldman and S.A. Lasher, The End-of-Life Handbook, New Harbinger Publications, Inc, 2007.

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