When Hospice Becomes a Barrier to Emergency Care in Nursing Homes and Assisted Living Facilities

At Nursing Home Law Group, we represent individuals and families in cases of neglect and abuse in nursing homes and assisted living facilities throughout California. For more than twenty five years, our practice has focused on protecting vulnerable elders and holding facilities accountable when they fail to provide safe, appropriate care.

For many years, hospice rarely played a role in the cases we handled. That has changed dramatically.

Today, hospice providers are involved in nearly half of our nursing home and assisted living cases. Often they are not named as defendants. But their involvement frequently creates confusion, delays, and missed opportunities to provide life saving care. In some cases, hospice status becomes the very reason a resident does not receive emergency treatment at all.

This trend should concern every family with a loved one in long term care.

Because hospice is meant to provide comfort at the end of life. It is not meant to become an excuse for inaction.

The pitch families keep hearing

Over the past decade, we have heard the same story from families again and again.

A staff member approaches them and asks a simple question.

“Have you considered hospice?”

The family is often confused. Their mother or father is not dying. They may be frail, but they are stable. They might have dementia or chronic medical issues, yet they are still enjoying meals, visitors, and daily activities.

When the family expresses hesitation, the facility reassures them.

“Hospice is not just for the dying anymore. It is just extra care. Medicare pays for everything. It costs you nothing.”

That sounds harmless. Who would not want more care at no cost?

So families agree.

A specific hospice company is recommended (is there a kickback?). Paperwork is signed. A physician certifies that the resident has a life expectancy of six months or less. And just like that, the resident is placed on hospice.

But here is the problem.

Many of these residents are nowhere near the end of life.

How hospice changes everything inside a facility

Hospice can absolutely be appropriate when someone is truly terminal. For the right patient, hospice provides compassionate comfort focused care, pain control, and emotional support.

The issue arises when hospice is used routinely for residents who are not actually dying.

Because once a resident is labeled hospice, the culture of care changes.

Staff begin to see that person differently. Subtly, sometimes unconsciously, the resident is treated as someone who is already at the end. Expectations drop. Urgency fades.

And in an emergency, hesitation creeps in.

In theory, hospice does not mean do not treat. It does not automatically mean do not call 911. It does not eliminate a patient’s right to life saving care.

In practice, however, we repeatedly see something else.

We see staff pause.

We see nurses call hospice first instead of 911.

We see facilities waiting for “instructions.”

And sometimes, we see nothing happen at all.

When confusion turns deadly

Consider a few common scenarios we encounter in our cases.

• A resident falls and hits her head. She becomes confused and lethargic. Instead of calling emergency services immediately to rule out a brain bleed, staff call hospice. Hours pass while they wait for a hospice nurse to arrive.
• A resident develops sudden shortness of breath and chest pain. Rather than activating emergency protocols, staff assume it is “part of the dying process.” No ambulance is called. The resident suffers a treatable cardiac event.
• A diabetic resident becomes unresponsive from low blood sugar. Staff hesitate because they are unsure whether aggressive intervention is appropriate for someone on hospice.

In each of these situations, the problem is not the resident’s condition. It is the label.

Hospice status creates uncertainty about what is allowed. And in healthcare, delay is often the difference between recovery and tragedy.

Families are frequently shocked when they learn that their loved one could have received emergency treatment but did not simply because staff believed hospice meant “comfort only.”

That is not what hospice is supposed to mean.

Hospice does not equal do not treat

This is one of the biggest misconceptions.

Hospice is about goals of care, not automatic withdrawal of treatment.

Unless there is a clear Do Not Resuscitate order or specific limitation documented, residents are still entitled to evaluation and emergency response. They can still go to the hospital. They can still receive antibiotics, fluids, or life saving interventions.

But assisted living staff and even some nursing home personnel are not always well trained on these distinctions.

So they default to caution.

And caution too often becomes neglect.

The uncomfortable truth about hospice certifications

There is another issue that families rarely see.

Hospice eligibility is based on a physician certifying that a patient is likely to live six months or less if the disease follows its normal course.

For someone with end stage cancer, that may be straightforward.

For chronic conditions like dementia, general weakness, or “failure to thrive,” it is much more subjective.

That gray area makes the system easy to manipulate.

We regularly see residents who remain on hospice for years. Some are discharged and then re certified repeatedly. Others show no clear decline but remain labeled terminal.

Why?

Because hospice is paid on a per day basis by Medicare. The longer someone stays on service, the more revenue is generated.

When facilities routinely recommend specific hospice providers and those providers consistently certify marginal patients, it raises serious questions about financial incentives.

Federal regulators have already begun investigating widespread hospice fraud. In California, enforcement has not kept pace with the explosion of new hospice companies. Oversight is limited. Audits are rare. And vulnerable seniors become the collateral damage.

What families should know

If your loved one is offered hospice, ask questions.

• Why is hospice medically necessary right now?
• What specific diagnosis qualifies them?
• Does hospice change whether 911 will be called in an emergency?
• Can we still choose hospitalization?
• What are the limits, if any, on treatment?

Get the answers in writing.

Make sure staff understand that hospice does not mean “do nothing.”

And trust your instincts. If something feels wrong, it probably is.

Accountability matters

Hospice, when used properly, is a compassionate and valuable service.

But when it is pushed as a routine add on, or used to reduce a facility’s responsibility for hands on care, it becomes dangerous.

No one should lose their life because staff were unsure whether they were allowed to call 911.

No one should be labeled “dying” simply because it is convenient or profitable.

At Nursing Home Law Group, we have seen firsthand how these decisions play out behind closed doors. When facilities allow confusion or financial incentives to interfere with basic medical response, families deserve answers and accountability.

If your loved one suffered harm after being placed on hospice or if you believe a medical emergency was ignored because of hospice status, you are not alone. These cases are becoming more common across California.

And they should never be dismissed as “just part of the process.”

Because hospice is meant to provide comfort.

It is not meant to cost someone their chance at care.