Hospice Care Planning: It’s a Powerful Asset Protection Option

Hospice Care Attorney in New Jersey

Has Your Doctor Recommended Hospice Care?
Do You Need to Get Your Final Affairs in Order?

It’s not easy for me to write about hospice and end-of-life planning. Until the reality of a hospice recommendation comes up, it’s a topic people think will continue to deflect them since the reality of (their) death is always a future event.

I know this is a difficult time for you or a family member/loved one who has either elected to enter hospice or is contemplating hospice in lieu of continued medical care.  For you, a family member, or a close friend, the reality of death is close at hand. For that, I am truly sorry unless of course death is welcomed over the burdens and struggles of continued life. Living long and dying slowly is a subject I discuss often with my declining elderly clients with advancing age.

You may find it surprising that someone (especially an elder law attorney) would address the topic of hospice on a dedicated webpage. The reality is however that I confront the death of clients weekly and I consider it to be a privilege to assist them during this anxious, emotionally painful, and disruptive period in their personal and/or family life. That’s why I’ve written this webpage to give you helpful and practical information about hospice, hospice planning, and end-of-life decision-making. With the insights gained working with thousands of clients many of whom have labored through the hospice journey, I’m confident I will be able to help you navigate through the many questions, challenges, and decisions that now must be made.

Dying With Dignity Makes Hospice So Beneficial 

If your physician has recommended hospice for you or a family member, you likely have lots of questions. What is hospice? How does one enroll? How much does it cost? And perhaps how it differs from traditional medical care under Medicare or traditional health insurance plans.

Hospice Philosophy: Living Well Until We Die

Patients and families who face a terminal illness will most likely (at first) focus on the impending loss of life. However, hospice programs encourage them to make the most of living and enjoying what may be a person’s last days/months. Staying at home lets patients reunite with friends and family members. It gives everyone a chance to reminisce and laugh together, despite the sadness, anger and pain that often accompanies death. Hospice lets patients live until they die — enjoying life to its fullest potential.

What is Hospice Anyway?

More than just a place to receive medical care and services, hospice is an approach for persons nearing the end of life. Its goal is to enhance the quality of life with a terminal illness. Hospice focuses on pain management and symptom relief, while addressing the patient’s emotional, social and spiritual needs—as well as those of family members. Hospice lets patients and families share the end-of-life experience with dignity and, in most cases, in the comfort of their own homes.

Each person entering a hospice program gets an individualized care plan. This plan is developed by a team of professionals and volunteers working with the patient and family members. Depending on the patient’s needs, the team may consist of the patient’s primary care physician, a hospice physician (or medical director), nurses, home health aides, social workers, clergy, trained volunteers and speech, physical and occupational therapists.  Visit Hospice Care of New Jersey (Click here for more information).

Why Choose Hospice?  Why Not Fight Death to the Bitter End?

A patient with a life-ending illness may reach a point where he or she (1) no longer responds to treatments aimed at curing the disease, or (2) considers death preferable over continued life.  At that time, a physician may recommend a shift in focus from curing the disease to making the patient as comfortable as possible until his/her passing. This shift from curing the condition to palliative care is “comfort-oriented” rather than “cure-oriented.”

“Palliative care” and “comfort care” are terms often used interchangeably to describe an approach to caregiving that seeks to provide physical, psychosocial and spiritual comfort to a patient. Palliative care can be used in conjunction with limited curative treatment. In the past few years, some physicians and other caregivers have embraced the concept of palliative care and are using its techniques with their (non-hospice) patients, mainly those in hospitals and nursing homes. Palliative care in those settings can provide a helpful transition to hospice services.

Hospice is specifically intended and designed for the terminally ill – that is, when a cure is no longer possible or when the side effects of curative treatment have become too burdensome for the patient.

It is treatment and care that seeks to control symptoms and manage pain. When the physician’s estimation of the patient’s life expectancy is (generally) six months or less, hospice care often is the best option.

Although some hospice care is administered in assisted living facilities, nursing homes, hospice centers, and inpatient settings, approximately 80 to 90 percent of hospice services occur in the patient’s own home. That’s partly because advances in technology have made it possible to provide many medical services, equipment and hospice services in a home setting by hospice team members.

These services include:

• Pain and symptom management
• Assistance with emotional, psychological, social and spiritual requests
• Drugs, medical supplies and equipment
• Training for family caregivers to provide daily care & assistance
• Speech, physical and occupational therapy as appropriate
• Arrangements for respite care to help provide breaks to family members
• Bereavement counseling for surviving family members and friends
• Help with day-to-day chores, hygiene, and activities of daily living
• Experienced counseling for end-of-life decisions
• 24-hour on-call availability for necessary & desirable services
• Nursing services

What type of treatment and medications does a person receive should he/she elect Hospice?

The purpose of hospice is to provide comfort to a terminally ill person. This includes relief from pain. To achieve maximum relief from pain, it is usually necessary to administer morphine, which is an approved medication (narcotic).

Prescription and narcotic drugs have a proper and constructive role in pain management and using drugs for this purpose is endorsed by the federal government. But you can also choose not to take narcotic drugs! It’s YOUR choice! Sometimes, hospice staff can reduce a patient’s pain and increase comfort through “complementary therapies” such as Reiki, aromatherapy and massage.

Many terminally ill patients receiving medication(s) for pain relief gradually build up resistance to these medications and can tolerate much higher levels of medication without fear of addiction. As much as a hospice patient has a limited life expectancy, it is highly unlikely that addiction will develop, and so elevated amounts of drugs can be authorized.  Remember, when hospice is elected, the patient is choosing comfort care over being cured of their illness and/or disease and/or injury.

Understanding Those Hospice Services Available to You

Is there such a thing as round-the-clock care from hospice?

Hospice care is an intermittent care program, meaning that care is provided through visits by hospice team members.

Hospice does not provide ongoing 24-hour care for the patient at home, nor does hospice provide caregivers for the eight to 10 hours a day when a family member is away at work. Hospice care provides support to the family – it does not replace the family. Hospice care is delivered through visits by nurses and counselors, by volunteers (if the family wishes), and by home health aides (if the hospice determines appropriate need).

If no one is available around the clock to care for the patient, families can seek ideas from the hospice social worker about how things can be “pieced together” to provide an appropriate level of care and companionship. Families can look at:

• Splitting the caregiving duties so each family member has a “shift.”
• Having one or more family members take reduced hours at work.
• Chipping in on payments to one family member who takes a leave of absence from work to stay at home with the patient.
• Bringing in a relative or friend whose time is more flexible.
• Hiring a companion for the patient while family members are at work.
• Placing the person in a full-time assisted living or skilled nursing facility

Caring for a hospice patient at home is often difficult, sometimes exhausting, and always requires adjustment and extra effort by the family and/or spouse. Nonetheless, families see hospice care at home as the final gift they can offer their loved one, and many family members say they are glad they chose hospice, despite the extra effort.

It’s about family: Get help taking care of a hospice patient?

Hospice is all about helping families care for their loved ones. Hospice staffers provide direct care to the patient and education to family members about providing care.

As I mentioned earlier on this page, hospice does not provide 24/7 care around the clock, nor does it provide shift care. If the family feels they must hire a companion for the patient for any portion of the day, they are free to do so privately. The hospice’s social worker can help the family identify resources that might help.

What to do if family members can’t handle a loved one at home?

Caring for a patient at home can be stressful and tiring.

There are valid reasons when a family might not be able to handle caregiving at home, and these will be among the first issues to be addressed by the hospice team. Perhaps the only other person living with the patient is a weak or elderly spouse or parent. Perhaps the home or neighborhood is not a safe location for caregiving that involves narcotic pain relief. Perhaps work schedules of adult children cannot be reduced or juggled.

Many families who do not believe they can manage a loved one, in fact, learn to do so with simple and proper training from the hospice team. Family members are not expected to become nurses, doctors or counselors. They must, however, be willing to provide more time and attention to their loved one. This must be understood from the beginning.

Useful parallels can be drawn between caring for a newborn and caring for a hospice patient. The physical aspects of caregiving to an infant or hospice patient are messy and tiring. Also, the entire household tends to focus on the newborn or the hospice patient. There are many changes in routine, and possibly some emotional stresses will come out. The major difference is between the joy of a newborn and the sadness of losing a loved one. One approach to think about is providing care to the hospice patient with the same love and patience as you would to a newborn.

Your hospice caregivers are very experienced in these matters. Remember that the patient and family are the backbones of hospice care. It is OK to “unload” your concerns on the hospice team and let them know you are tired and stressed out. They will have helpful ideas on how to cope. This is their profession and for many, it is their passion. They are good and compassionate individuals.

Medicare Eligibility Requirements to Receive Hospice Care

Medicare pays a great deal of the services provided by Hospice throughout the country. In order to be eligible, a patient must be covered under Medicare Part A and must also have a certification from a physician that the patient’s life expectancy is six months or less, assuming the illness runs its normal course. There is a great deal of confusion about the six-month standard. It does not mean that the patient will lose his or her Hospice benefits after six months. Instead, it simply means that in order to be eligible, there must be a six-month life expectancy. After the initial period of certification, however, the patient can have an unlimited number of additional sixty-day periods. So long as the individual continues to have a life expectancy of six months or less, Hospice can go on indefinitely. As a side note, I’ve noticed a recent trend under Medicare approving hospice when the prognosis of death is beyond six(6) months. Why this is happening I’m not sure, so perhaps with some sincere advocacy, you’ll be able to persuade your physician to approve a hospice referral.

To enroll in Hospice, the patient must sign a statement electing the Hospice benefit. This is perhaps the most difficult step for many families to take since this election shifts the course of treatment from curative (i.e. intending to help the patient get better) to palliative (i.e. treating the pain, but not trying to cure the illness). Many patients worry that by electing the palliative (pain reducing) course of treatment, they are locking themselves into something that cannot be changed. That is not correct. The election from Hospice to non-Hospice to Hospice care can be made as frequently as the patient desires.

A great benefit of Hospice care is that the medication related to the terminal illness is covered with a maximum co-pay of five dollars per prescription. In this day and age of spiraling medication costs, this benefit alone can save families a tremendous amount of money. In addition, the new Medicare law added another valuable Hospice benefit. Under the law, patients can have a one-time educational consultation by a Hospice physician to the terminally ill patient, even when that patient is not yet in Hospice. The consultation can occur in a care facility or at home, and can also include a pain assessment, along with counseling on care options and advance planning.

The question frequently arises… does Hospice pay for nursing home care? If the patient is a nursing home resident, there will be Hospice benefits available, much like if the resident were at home. The Medicare Hospice benefit will not cover the costs of room and board at the nursing facility or an assisted living facility. Medicare will, however, continue to cover the types of services mentioned earlier unrelated to room and board.

What if the person is not on Medicare Part A? Are there other ways to receive Hospice care?

In addition to Medicare, there are many ways that Hospice care may be paid for. Often, private health insurance, Health Maintenance Organizations (HMOs) and managed care organizations cover the cost of Hospice care. In addition to Medicare, for military patients as well as those covered by CHAMPUS (the health benefits program for retired military personnel and dependents) will frequently cover the cost of Hospice. Additional funding for Hospice also comes from community contributions, memorial donations and foundation gifts. Many Hospice programs also use a sliding-fee scale, based on a patient’s ability to pay for services when insurance and other benefit programs are not available.

Recent Speaking Events by Fredrick P. Niemann, Esq.
You Can View Fred’s Current Schedule by Clicking Here

Do you have questions about hospice not addressed here? If so, contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com to schedule a consultation about your particular needs. He welcomes your calls and inquiries and you’ll find him very approachable and easy to talk to.

Fredrick P. Niemann, Esq. was recently asked to speak at the NJ State Bar Association Institute of Continuing Legal Education in New Brunswick, NJ on the essentials of estate planning.

Mr. Niemann addressed attorneys from throughout the state of NJ interested in learning key concepts and principles of NJ estate planning, including such topics as wills, trusts, estate taxations, asset protection, powers of attorney, health care directives, special needs and supplemental needs trusts for disabled and incapacitated individuals, avoiding probate through the creative use of beneficiary planning, inheritance taxes, gifting and changes coming to federal estate taxation.

Fredrick P. Niemann, Esq. attended the 46th annual Heckerling Institute on Estate Planning Conference from January 9th to January 13th at the Orlando World Center sponsored by the Community of Miami School of Law. This weeklong session assembled the nation’s leading authorities to lecture and discuss the latest in estate planning techniques and strategies. Topics analyzed and discussed included 1) elder law; 2) asset protection; 3) statutory case law developments; 4) planning with financial assets including annuities, Roth IRA’s, and life insurance policies; 5) litigation and tax controversies; 6) networking and practice development.

Hospice Care attorney serving these New Jersey Counties:
Monmouth County, Ocean County, Mercer County, Middlesex County, Bergen County, Burlington County,
Union County, Passaic County, Somerset County, Morris County, Hudson County