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 facto full 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.
