Most people, even many doctors, are unsure how to talk about end-of-life care. Yet it is one of the most important and meaningful conversations you can have with a loved one. When an ailing elderly person must leave a hospital, or can no longer live independently, they often must choose between going to hospice care or a nursing home.
Our nursing home lawyers discuss the differences between and benefits of each system.
If you read our last post, you know the country is facing a shortage of elderly-care doctors at the same moment a large part of our population – one in five Americans by 2030 – transitions into retirement. As the baby boomers age, it’s increasingly important to discuss end-of-life plans, not only with doctors but with family and close friends as well.
Advanced care planning can include
- Insurance billings (will they use Medicare, Medicaid, or private insurance? Do they have long-term care insurance?)
- Do-not-resuscitate orders
- Living wills, power of attorney, advanced directives, and other legal documents
- Burial and funeral wishes
Families deciding to admit a loved one to a nursing home should prepare to monitor, constantly, how staff treats and cares for them. Nursing homes offer skilled medical care for patients that need constant or specialized monitoring. They do not address end-of-life issues, like spiritual or familial support, dietary requests, or social needs, unless the resident is in a special hospice or palliative care unit.
Nursing homes are the only places that offer round-the-clock, long-term care. Staff is trained to give residents aggressive medical interventions, regardless of whether they’re in their final weeks or days of life. These interventions can be expensive, painful, and unnecessary.
For those of you in Illinois, Maryland, and a handful of other states, recently enacted laws allow you to place video cameras in residents’ rooms (with the permission from any roommates). These laws follow severe nursing home abuse lawsuits, where families suspected their loved one was suffering abuse but had no way to prove it.
Medicare and Medicaid
Medicare is available for people aged 65 and older, people younger than 65 with specific conditions, and those with kidney failure. Medicaid covers people with severely limited finances.
Medicare offers a skilled-nursing facility (“SNF,” but more commonly known as nursing home) benefit, under which recipients are entitled to up to 100 days in a nursing home after being in the hospital for at least three days.
Medicare pays for the cost in full for the first 20 days, and after that,the patient is responsible for a co-payment of about $145 per day. If a resident cannot pay this, either family or Medicaid would have to cover the costs.
This is because Medicare’s nursing home benefit is meant to provide rehabilitation after an accident or hospital visit. The intention is for the patient to get well enough to return home. Medicare very rarely provides for hospice care in nursing homes.
There is one caveat: if the resident leaves the nursing home because of a medical emergency, and is admitted for more than three days, their nursing home benefits renew. This gives nursing homes an incentive to admit residents to hospitals, since Medicare reimburses at higher rates than Medicaid.
One study looked at about 5,000 Medicare beneficiaries from 1994 to 2007. During that time, one-third used their Medicare nursing home benefits in their final six months. About 43% of those people died in the nursing home,40% died in a hospital, and 11% died at home. The beneficiaries who did not use their Medicare nursing home benefits died most often at home (over 40%).
Hospice is a specific type of palliative care meant for people in their last six months of life. It’s designed to treat the whole person – physical, emotional, spiritual – not just their disease or condition. Hospice teams include a wide range of specialists, from doctors and pharmacists to dietitians and volunteers. They focus on relieving suffering, making the patient and their family as comfortable and supported as possible during their final days.
This can include grief counseling, speech therapy, therapeutic massage, and religious support, among many other services.
Some hospitals and nursing homes offer hospice, but not all. Hospice is most often provided at home.
Patients can choose to enter or leave hospice at any time. If your illness improves or you choose to seek alternative treatment, you are free to leave and return later. Most private insurers cover hospice care benefits.
Medicare and Medicaid
The extent of Medicaid coverage varies widely by state. The program offers hospice benefits in 45 states and Washington D.C.
Medicare covers hospice if you have two doctors determine that you have 6 months or less to live, although some states cover hospice for up to one year. Terminally ill patients can receive hospice for as long as necessary.
Medicare patients generally cannot use hospice services while in a nursing home. The exceptions are if the patient is not enrolled in the nursing home Medicare benefit, or if the reason they need nursing home care and hospice care are unrelated (which is unlikely).
For example, if a patient enters a nursing home because she suffered a brain bleed, and it’s later discovered she has cancer, she could receive both hospice and nursing home benefits, because the two are unrelated. If her cancer caused her brain bleed, Medicare would only cover one.
Even if the resident chooses to receive hospice care, Medicare does not pay for room and board, forcing the resident to pay hundreds of dollars per day out-of-pocket.
Patients could use their hospice benefits at home, but it isn’t 24/7,so daily tasks and medical care is left to families. If family or friends cannot handle the level of skill or time required, they could hire an outside agency for help. The median price for at-home care is $20 per hour.
Where to Start
So how should families navigate the complex and overwhelming waters of end-of-life care? It should begin with honest conversations with loved ones, before medical emergencies or life-threatening illness. If your family is already facing a chronic or severe condition, have an honest discussion with them and their doctors.
Doctors should be open to telling the family exactly what their prognosis is, if they can recover within a few weeks or months, or if they will likely die within a year or less. Medicare now reimburses doctors to discuss end-of-life care during office or hospital visits.
We represent nursing home residents suffering serious injury nationwide. For over 30 years, we’ve helped residents and their families through what is often the most difficult time in their lives. Our legal consultations are always free, and we work on a contingency fee basis, so we never charge any attorneys’ fees out-of-pocket.
Call or email us if you have any immediate concerns, or follow us on social media @NationalPILaw for up-to-date information on nursing home laws, cases, and industry news.