Why Hospice Care Exists
What is Hospice
How Hospice Care Works
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Choosing A Hospice
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  1. What can we expect from the Autumn Journey Hospice staff?
  2. When is hospice appropriate?
  3. Should I wait for our physician to bring up the subject of hospice or can I ask about it first?
  4. What if our physician doesn’t know about hospice?
  5. When should a decision about entering a hospice program be made and who should make it?
  6. Where do I go to receive hospice care?
  7. Is it true that hospice is where you go when there is “nothing else to be done”?
  8. What if I don’t understand what is happening and don’t know how to make the right decisions?
  9. What does the admission process involve?
  10. How do I refer someone to Autumn Journey Hospice?
  11. Can I keep my regular doctor?
  12. Who pays for hospice services?
  13. If the patient is eligible for Medicare, will there be any additional expenses to be paid?
  14. Do I lose any Medicare benefits because I am on Medicare hospice care?
  15. I’ve heard that hospice agencies provide unnecessary services so they can make more money. I’ve also heard that hospice agencies can use up my Medicare benefits by providing unnecessary services. Is this true?
  16. Are you a for-profit or a non-profit agency?
  17. What if I do not have Medicare, Medicaid or private insurance or enough personal income to pay for services?
  18. When does hospice care stop?
  19. Can an Autumn Journey Hospice patient who shows signs of recovery be returned to regular medical treatment?
  20. What if the patient wants to transfer to a different hospice agency?
  21. Is there any special equipment or changes I have to make in my home before hospice care begins?
  22. How many family members or friends does it take to care for a patient at home?
  23. How difficult is caring for a dying loved one at home?
  24. What if we have a problem on a week night, weekend or holiday?
  25. Does Autumn Journey Hospice do anything to make death come sooner?
  26. How does Autumn Journey Hospice manage pain?
  27. What is Autumn Journey Hospice’s success rate in controlling pain?
  28. Will medications prevent the patient from being able to talk or know what is happening?
  29. Does Autumn Journey Hospice provide any help to the family after the patient dies?
  30. Is Autumn Journey Hospice affiliated with any religious organization, other hospice, nursing home or residential assisted living home?
  31. Is hospice care is more expensive than regular care?
  32. How does Autumn Journey Hospice use and/or disclose my personal health care information?
  33. Do you provide care to clients in nursing homes?
  34. What are the physical signs of imminent death?

1.   What can we expect from the Autumn Journey Hospice staff?
Our interdisciplinary team is made up of very experienced health care professionals and volunteers. Each is highly skilled, very experienced and specially trained to meet the needs of the terminally ill, their families and caregivers.

Our team is headed by our Medical Director who is a doctor of internal medicine.  Together with the prospective client’s primary physician, if any, our Medical Director determines an individual’s eligibility for hospice.  Our Medical Director also consults with the primary physician and our interdisciplinary team to develop the client’s plan of care. With the help of the hospice team, the Medical Director monitors our client’s condition and prescribes palliative medications as needed to ensure he or she is as free as possible from any pain or symptoms.

Our registered nurse case manager makes regularly scheduled visits at least twice weekly and more, if needed, to provide expert pain management and symptom control care. The case manager provides training and counseling to the primary caregivers and client to ensure care is provided properly and safely. The case manager also keeps the primary physician and our Medical Director informed about the client’s condition.  Support from a registered nurses is available, as needed, on a 24/7/365 basis.

Social workers provide assistance with practical and financial concerns as well as emotional support, counseling and bereavement follow-up. They evaluate the need for volunteers and other support services needed by the family and facilitate communication between the family and community agencies.  Social workers typically visit two times each month and more, if needed.

Chaplains provide non-denominational spiritual support to clients and families, often serving as a liaison between them and their religious community. They offer support services ranging from counseling to crisis help to grief support. Chaplains also often assist with memorial services and funeral arrangements.  Our chaplains normally visit two times each month and more, if needed.

Our certified nursing aides (CNAs) function as home health aides, providing personal care and assistance with activities of daily living, feeding and bathing and hands-on care. They also perform limited household services to maintain a safe and sanitary environment in the areas of the home most used by our client.  Our CNAs usually visit 3 to 6 days each week, depending on the client’s need.  We also have our CNAs visit clients who have hired caregivers in place or who live in group homes or other facilities where caregivers are provided.  We do this to ensure our clients receive the care they need.

Trained volunteers provide a number of important services. Volunteers offer direct client support, companionship and practical, caring help.  They can assist the primary caregivers by sitting with our clients to provide the caregivers respite from the sometimes overwhelming task of providing around the clock care for a loved one.  Volunteers also spend time with caregivers and families when asked to provide an emotional break from caregiving. Volunteers may also provide non-direct client support by assisting the agency in its office and clerical work.

Finally, the most important thing you can expect from the Autumn Journey Hospice staff is an aggressive, passionate belief in, and adherence to, our philosophy of hospice client care. This short verse perhaps best describes our philosophy.

“Now take my hand and hold it tight.
I will not fail you here tonight.
For failing you, I fail myself
And place my soul upon a shelf
In Hell’s library without light.
I will not fail you here tonight.”

2.   When is hospice appropriate?

Hospice care becomes an appropriate method of care when an individual has reached the last phase of a life-limiting illness or condition.  Hospice care can be discussed at any time as the individual and his/her physician discuss treatment options.

When an individual chooses hospice, he/she makes the decision to discontinue curative measures in favor of comfort care that focuses on pain management and symptom control, as well as emotional and psychosocial support for both the individual and his/her family.

3.    Should I wait for my physician to bring up the subject of hospice or can I ask about it
The affected individual, with the input of family members and his/her physician, as desired, should make the decision to receive hospice care.  Open and honest discussions about treatment options should take place throughout the course of the illness or condition.  If an individual or family member feels that a physician is reluctant to discuss hospice care, it is always appropriate for either to approach the subject.  The physician may have a list of hospices he/she routinely uses.  However, by Medicare regulation it is an individual's right to select the hospice agency of his/her choice

4.   What if my physician doesn't know about hospice or doesn't believe in hospice?
Most physicians know about hospice.  However, if your physician would like more information, he or she may email us at wecare@autumnjourneyhospice.com or call us at (972) 233-0525. 

The decision to receive hospice care belongs to you, not your physician.   If your physician will not provide a referral to a hospice agency, you are always welcome to transfer your personal care to the hospice agency's Medicare Director (ours is a Doctor of Internal Medicine).  Approximately 75% of our clients use our Medical Director as their personal physician.

5.   When should a decision regarding hospice care be made and who should make it?
It is appropriate to discuss all available care options, including hospice care, at any time during a life-limiting illness or condition.   The decision regarding hospice care belongs to the prospective client or his/her properly assigned medical representative or power of attorney.

There is no definite time to begin hospice care because each client/family situation is different; however, Medicare studies and our experiences have shown that early referrals are very beneficial both physically and emotionally.  An individual should consider hospice care when he/she enters the final stage of life and he/or she and family members need help and counseling to adjust to the diagnosis, learn how to provide care at home and prepare for future changes.

Understandably, most people are uncomfortable with the idea of stopping an all-out effort to overcome an illness or condition.  Our staff members are highly sensitive to these concerns and are always available to discuss them with the individual, family members and his/her personal physician.

We would like to take this opportunity to clear up a misconception regarding hospice care. Unfortunately, many people believe the use of hospice care somehow guarantees they have less than six months to live.  Medicare has provided the following explanation and clarification to physicians regarding hospice care. Medicaid and private insurance providers use this same philosophy.

“Generally speaking, the hospice benefit is intended primarily for use by clients whose prognosis is terminal, with six months or less life expectancy.  However, the Medicare program recognizes that terminal illnesses do not have entirely predictable courses.”

“Recognizing that prognoses can be unpredictable and may change, Medicare’s benefit is not limited in terms of time. Hospice care is available as long as our client’s prognosis meets the law’s six month test. This test is a general one……based on the physician’s and/or Medical Director’s clinical judgment regarding the normal course of the individual’s illness. Medicare recognizes that making medical prognostications of life expectancy is not always an exact science.”

6.   Where do I go to get hospice care?
We provide the majority of our care in our client’s home with family and friends acting as caregivers. If our client no longer lives at home, we can provide care wherever he/she lives, including retirement homes, nursing homes*, residential assisted living homes (group homes) or other types of long- term care facilities. If a client requires short-term care in a hospital to treat severe symptoms or in a care facility to provide respite for a caregiver, we will arrange it. There is no charge to the Medicare or Medicaid client for hospice care.  Many private insurance plans also pay for hospice care.

*  Please see question 33 for more information about nursing homes.

7.   Is it true that hospice is where you go when there is “nothing else to be done”?
Hospice is the “something else” that can be done for the individual and family members when an illness or condition becomes life limiting.  Admission to hospice is a transfer to comfort-oriented care developed specifically for each client.  Our emphasis is on pain and symptom control, as well as helping the client and family experience the highest possible quality of life each day.

8.   What if I don’t understand what is happening and don’t know how to make the right 

We are available to provide the information and education prospective clients and families should have in order to make informed decisions about hospice care.  The individual and family should consult with his/her physician and a hospice representative to ensure all questions are answered and all concerns are discussed.  You may also search our Links to Information Sources to help you find answers to some of your questions.

9.   What does the admission process involve?
A phone call to Autumn Journey Hospice at (972) 233-0525 is all that you need to do to start the admission process.

One of the first things we will do is contact the individual’s physician, if any, to ensure he/she agrees hospice care is appropriate.  One of our registered nurses and social workers will then visit the prospective client and family to ask questions about the prospective client's health and previous health care.  They will also ask questions about the home and family environment that could affect the way in which we provide care.

The nurse will explain the issues the prospective client and family members can expect from hospice care, how we provide care, the services we provide and information on the illness or condition that will help prepare everyone for the future.  The nurse will complete the admission by conducting a medical assessment consisting primarily of questions about the client’s health history and current health status.  While some measurements, such as checks of blood pressure and oxygen saturation level, will be made, the assessment will not be a “hands on” physical.

The social worker will assist the client in completing forms required by Medicare/Medicaid, as appropriate.  The social worker and nurse will also discuss the Medicare, Medicaid and/or other available benefits, if any, and answer any questions the client or family may have.

The admission process will take two to three hours.  When the admission is complete, the nurse will immediately order any needed medications, medical equipment and medical supplies.  All of these items will be in your home in twenty-four hours or less at no charge.

10.   How do I refer someone to Autumn Journey Hospice?
A referral can come from the attending physician, a family member, a friend, clergy, a health care provider or even from the individual. You only need to call our office at (972) 233-0525 to provide your referral.

11.   Can I keep my own physician?
Yes.  If that is your desire, your physician will continue as your primary physician and will approve your admission to hospice care.  He/she will also consult with our Medical Director regarding delivery of our services to you and changes in your hospice plan of care. The hospice team members will work closely with your physician in administering and providing your care.

However, you and your physician may elect to have our Medical Director assume primary responsibility for your hospice care, since our hospice Medical Director has extensive experience and expertise in the full spectrum of hospice and palliative care. In either case, we function as an extension of, rather than a replacement of, your primary physician.  Even if our Medical Director has primary responsibility for your care, your physician will always receive updates on your status and the status of your care. Your physician also will continue to provide Medicare Part B care to you as you may desire and will be able to continue billing Medicare for the care he/she provides.

Our Medical Director is also available to serve as the primary physician for clients who do not have one.

12.   Who pays for hospice services?
Hospice care coverage is widely available.  We are a state licensed and Medicare/Medicaid certified agency. For those eligible for Medicare Part A or Medicaid healthcare coverage, all hospice care costs are covered.

Many private insurance carriers pay 80% to 100% of hospice charges up to a pre-determined limit.  If you have private insurance, you should contact your provider to determine your coverage limits and whether deductible or co-payments will be required.

13.   If I am eligible for Medicare and/or Medicaid, will I have to pay for anything
        for my hospice care?
Medicare and Medicaid pay for all services and supplies related to the client’s terminal illness or condition.  Although Medicare does allow hospice providers to collect five percent co-pay on medications, preferred hospices agencies never ask for this payment.  In fact, you never receive a bill of any kind from us, Medicare or Medicaid. 

Please note that the Medicare Hospice Benefit does NOT include room and board costs in nursing homes, inpatient hospice facilities or residential assisted living homes.  Such costs remain the responsibility of the hospice client.

If you have private insurance, please contact your provider to determine if deductible or co-payments will be required.  Also, you should ask if your policy provides coverage for room and board expenses for hospice care.

14.   Do I lose any Medicare benefits because I am on hospice care?
No.  If you are using your Medicare Hospice Benefit, it is important to understand that we  only use the portion of your Medicare Part A benefit (hospitalization) related to the medical diagnosis that qualified you to receive hospice care. The remaining portion of your Medicare Part A benefit and all of your Part B benefit (physician visits) continue to be available for your use.  You will still be able to consult with your physician. Your physician also will be able to be reimbursed for the care and services he/she provides to you.

15.   I’ve heard that hospice agencies provide unnecessary services so they can make
        more money.

        I’ve also heard that hospice agencies can use up my Medicare benefits by providing
        unneeded services.  Is this true?

Our answer is long because we want you to understand how hospice care works.

Unlike most other providers in the healthcare industry, hospice agencies do not bill Medicare, Medicaid or private insurers for specific services.  We are paid a fixed per diem amount for the hospice care we provide. This being the case, you should actually be concerned if you see LESS rather than MORE hospice services provided.

The primary way a hospice agency can increase its profit is by controlling costs. The primary way to control hospice care costs is to limit the amount of care provided.  So, you should monitor the hospice agency to ensure that an adequate number of regularly scheduled visits are made by ALL the members of the Interdisciplinary Team….that is, the registered nurse Case Manager, the social worker, the chaplain and the home health aide. You should ensure that you understand and agree with the Plan of Care developed by the Interdisciplinary Team members and the Medical Director, and approved by the attending physician.  Hospice team visits and all aspects of care, including medications, are based on this Plan of Care.

Typically, you should expect:

  • RN Case Managers to visit at least twice each week and more if necessary.
  • Social Workers to visit two times each month and more if necessary.
  • Chaplains to visit two times each month and more if necessary.
  • Home Health Aides to visit at least three times each week. We typically increase this to five or six times each week, if our client needs or desires to have the added visits.

As part of your due diligence in choosing a hospice agency, you should ask each hospice agency what type of staff visitation schedule they use and what the schedule is based on.  You should also ask if the same team members stay assigned to your loved one’s care.  Some hospices schedule for their own convenience and do not always keep the hospice team intact. 

We believe it is very important the same team members make each visit to ensure a bond of trust is formed.  We also want our care to be provided by team members who have intimate knowledge of all aspects of the client’s physical and emotional condition, as well as the interactions among family members.

Some hospice agencies will limit expenses by asking clients to pick up their prescriptions at the pharmacy. We always deliver to your door at no cost.  Medical equipment and supplies will also be delivered at no cost.

Some hospice agencies may ask for a Medicare approved 5% co-pay for each prescription they provide. We never have and never will.

It is not possible for a hospice agency to “use up your Medicare benefits” since hospice agencies are only entitled to bill Medicare for that portion of your Part A (hospitalization) benefit that specifically applies to hospice care.  In fact, Medicare reimbursements to hospice agencies are limited to a maximum amount per client.  This limitation, or “cap”, is approximately 160 days of client care.

So, you may wonder, what happens at the end of this 160 day period? The short answer is that nothing changes.  We provide the same quality and level of care as we did for the first 160 days and we continue to do so as long as our client is under our care.

There is a simple explanation for this. In order for a hospice agency to maintain its Medicare certification, the agency MUST continue to provide all services care it has been providing. Also, the agency can NEVER discharge a Medicare client from hospice care simply because the “cap” limitation has been reached. To ensure care continues to be appropriate, Medicare requires its member hospice agencies to maintain meticulous records for each client to demonstrate the quality and amount of care being provided. These records must always be available for Medicare/State inspectors. You should never be concerned that Medicare hospice care might stop or that the quality of care might deteriorate.

If you have concerns about any aspect of the care your loved one is receiving, you should discuss them with the members of the Interdisciplinary Team and the hospice agency until you are satisfied. If you still have concerns after these discussions, then you may want to consider transferring to a different hospice.  Please see Question 20 for an explanation of the transfer process.

16.   Are you a for-profit or a non-profit agency?
We are a for-profit agency. We bill Medicare, Medicaid and private insurers for our services to our clients.

Both for-profit and non-profit hospice agencies have their places in the home health services community.  Both provide valuable and necessary care for their clients. Most importantly, both provide hospice care according to well-established, specific criteria mandated by the State and, where applicable, Medicare and Medicaid.

However, to answer the real question behind the stated question, let's take a look at the similarities and differences between for-profit and non-profit hospice agencies.

For-profit hospice agencies generate revenue by serving clients who have hospice care coverage provided by Medicare, Medicaid or private insurance providers.

Non-profit hospice agencies generate revenue in the same manner as the for-profit hospice agencies by serving clients who have hospice care coverage provided by Medicare, Medicaid or private insurance providers.  Non-profit hospice agencies also receive funding from charitable donations and, in some cases, grants.

When an individual does not have any type of hospice care coverage and cannot pay for hospice care (in other words, is unfunded), the non-profit agency will use the charitable donations and grants they have received to cover their costs of hospice care.  However, when the funding from donations and grants is used up, then non-profit agencies will limit the number of unfunded clients they serve. 

You can confirm this by contacting non-profit hospices and asking if they are accepting unfunded clients.  Quite often, particularly near the end of their fiscal year, their answer will be, “Not at this time.”  At that point, the non-profit hospice agency operates in exactly the same manner as the for-profit agency and accepts only those clients funded by Medicare, Medicaid or private insurance.

The reason for this is that non-profit hospice agencies have the same expense structure that for-profit hospice agencies do.  All of us have to generate enough revenue so we are able to stay in business to help future clients.

Some would have you believe non-profit agencies focus only on patient care while for-profit agencies are only interested in making money for their shareholders.  Each of these observations may or may not be true, depending on the corporate mindset and culture of each agency.  That is why the research you do before you choose a hospice is so important.

The question is how do you, as a consumer, choose an agency that provides hospice care in the way you expect it to be provided?  If you go to our "Choosing a Hospice" page, you can review a list of questions to ask and issues to consider before choosing a hospice agency.

17.   What if I do not have Medicare, Medicaid or private insurance or enough money
        to pay for services?
While our services are limited to those clients covered by Medicare, private insurance or direct pay, if you have no funds or hospice care insurance coverage, in most cases you can still receive hospice care.   Should you be in that situation, we will be happy to assist you with a referral to a hospice source appropriate for your needs.

18.   When does hospice care stop?
Hospice care is provided as long as our client continues to meet the Medicare, Medicaid or private insurance enrollment criteria and desires to have hospice care.

We also provide bereavement care for the family after our client expires. Medicare and Medicaid require hospice agencies to provide bereavement counseling and care for thirteen months.  We provide bereavement counseling care as long as required without regard for any time limit.

It is important to understand that a Medicare/Medicaid certified hospice agency cannot remove a client from hospice care unless one of the following conditions occurs.

  • The client moves out of the hospice agency’s service area or decides to transfer to another hospice.
  • The client makes the decision to resume curative treatment.  In this case, hospice care may be revoked and the client immediately resumes his/her regular Medicare coverage, including coverage for treatment of the hospice diagnosis. A client may, at any time, return to hospice care by re-enrolling with us or another hospice provider as long as the client is medically appropriate for hospice care.
  • The client is no longer eligible for hospice care, as determined by the client’s primary physician and our Medical Director.
  • The client’s (or other persons in the client’s home) behavior becomes disruptive, abusive or uncooperative to the extent that delivery of care and/or our ability to provide care effectively is seriously impaired.  We then must complete the following tasks before we can discharge a client for cause:

              -  advise our client (or client’s representative, if client is unable to make
                 decisions) that a discharge for cause is being considered;
              -  make a serious effort to resolve the problem(s) presented by our client’s
                 or another person’s behavior or situation;
              -  ascertain that our client’s proposed discharge is not related to our client’s
                 use of necessary hospice services;
              - document the problem(s) and efforts made to resolve the problem(s) and
                 include this documentation in our client’s medical records.

19.   Can an Autumn Journey Hospice client who shows signs of recovery be returned to
        regular medical treatment?
Certainly.  Our clients always have this option. If improvement in the condition occurs and the disease seems to be in remission, our client can be discharged voluntarily from hospice and return to aggressive therapy or go on about his or her daily life. If a discharged client should need to return to hospice care, Medicare/Medicaid and most private insurance companies will allow the client’s remaining benefit to be used as long as her or she is medically appropriate for hospice care.

20.   What if a Medicare hospice client wants to transfer to a different hospice agency?
A Medicare hospice client has the right to transfer from one hospice agency to another once during EACH benefit period without loss of any Medicare hospice benefits. Should a client decide to transfer a second time during a benefit period, he or she would forfeit the remainder of the current benefit period. However, since the Medicare benefit includes an unlimited number of 60-day benefit periods, the client can never use up his/her Medicare hospice benefit.

The transfer process is very simple, requiring only that the client or his/her legal representative write a one sentence letter to each hospice agency. The letter need only indicate that the transfer is taking place and the date of the transfer.  There is no requirement to provide a reason or any type of justification.  The letter to the previous agency should also contain a request that the client’s records be transferred to the new hospice agency. Most agencies have transfer forms available that make the process even easier. The two agencies will then coordinate to ensure that the transfer is completed smoothly and safely.

21.   Is there any special equipment or changes I have to make in my home before
        hospice care begins?
Autumn Journey Hospice will assess your needs, recommend any necessary equipment and help make arrangements to obtain it.   We supply required medical equipment at no charge as part of our service to you.

22.   How many family members or friends does it take to care for a client at home?
There is no set number.  The client’s condition, the relationships between family members and the mindset of everyone involved are just a few of the factors used to determine how many caregivers will be required.  Our client and/or the family and loved ones will determine how many caregivers are required and what type of schedule they follow.  One of the first things that Autumn Journey Hospice does is prepare an individualized care plan to support and meet the needs and goals of our client and family. Our staff members visit regularly and are always accessible to answer questions and provide support.

23.  How difficult is caring for a dying loved one at home?
It is never easy and sometimes can be quite hard. At the end of a long, progressive illness, nights especially can be very long, lonely and difficult. Through our RN Case Managers, licensed medical social workers and chaplains, we provide extensive counseling and support to help family members and caregivers during our client’s end stage of life.

24.   What if we have a problem on a week night,
        weekend or holiday?
Help from the Autumn Journey Hospice team is available on a 24/7/365 basis. We have registered nurses on call to resolve concerns by telephone or, as needed, with a visit. We are always available for our clients, their families and caregivers.

25.   Does Autumn Journey Hospice do anything to
        cause death to occur sooner?
Absolutely not.
Autumn Journey Hospice does nothing either to speed up or slow down the dying process.  Just as doctors and nurses lend support and expertise during the time of childbirth, so hospice provides its presence and specialized knowledge during the natural progression of the end stage of life.  Our purpose is to provide palliative care to ensure the best possible quality of life for the client, family and caregivers during the client’s end stage of life.

26.   How does Autumn Journey Hospice manage pain?
Our registered nurses and doctors are highly experienced in hospice and palliative care. They work diligently to know the most effective medications and devices for pain and symptom relief. We also believe that emotional and spiritual pains are just as real and in need of attention as physical pain, so we address these as well. Counselors, including pastoral counselors, are available to assist family members as well as clients.

We manage symptoms and pain very carefully.  We always begin pain control with the lowest medication dosage possible that still provides relief.  As clients who have issues with pain and/or shortness of breath are on medications for longer periods, some may develop an increased tolerance to pain medications.  This may make it necessary to increase the dosage for effective relief. 

At this point in the client’s life, pain medication dosages have almost no limit.  If necessary, we will prescribe as much as can be given safely to relieve pain or symptoms to an acceptable level. 

Quite often, the dosages we prescribe are significantly higher than what your personal physician may routinely prescribe.   Because we provide pain control daily for a wide variety of pain and symptom issues, we have more experience with pain reducing medications, as well as the tolerance levels our clients may develop to medications.  For this reason we are more comfortable using higher dosages to ensure pain is maintained at an acceptable level.

The only thing we will not do is use such a high dose of morphine or similar medications that the client is completely sedated a majority of the time, because there is no quality of life in that condition.

27.   What is Autumn Journey Hospice’s success rate in controlling pain?
According to our clients, our success rate is very high.
Using a combination of medications, counseling and therapies, most clients attain a level of comfort that is acceptable to them.  Because of our extensive experience in palliative care, we have very rarely encountered a situation where pain was not controlled to our client’s satisfaction.

28.   Will medications prevent me from being able to talk or know what is happening?
Usually not.

When clients begin taking medications like morphine, they often feel drowsy for a short period of time, typically a matter of days.  However, in most cases, they build up a resistance to the sedating effects. Most clients whose pain is well controlled on morphine are not bothered by unusual sleepiness. Some people, however, notice a difference in their alertness and may choose to accept less than complete pain control as a trade off. 

As mentioned above, we will not use such a high dose of morphine or similar medication that the client is completely sedated a majority of the time, because there is no quality of life in that condition.  Our goal is to help clients be as comfortable and alert as they desire.  By constantly consulting with our client, caregivers and family, Autumn Journey Hospice has been very successful in reaching this goal.

29.   Does Autumn Journey Hospice provide any help to the family after death occurs?
The Medicare Hospice Benefit provides bereavement support for family members and loved ones for a period of 13 months. We provide continuing contact and bereavement support to family members and loved ones as long they need us.

30.   Is Autumn Journey Hospice affiliated with any religious organization or other
We are a locally owned and independent organization.  We have no affiliations with any other hospice, hospital, nursing home or religious organization.  We are members of your community and are here to serve you.  We do not ask or expect clients to adhere to any particular religion or set of beliefs. We accept clients without regard for age, disability, race, color, creed, sex or sexual preference.

31.   Is hospice care more expensive than regular care?
No.  From Medicare's viewpoint, studies have shown that hospice care is less expensive than regular care.  

From our client's perspective, if he or she has Medicare Part A or Medicaid hospice coverage, hospice care is free and includes those medications related to the hospice diagnosis, medical supplies and medical equipment, all of which include free delivery to the client’s residence.  Family, friends and volunteers provide companion care at home.

If you have private insurance coverage, you should check with your provider to determine the amount and limits of coverage for hospice care, including any deductibles or co-payments.

32.   How does Autumn Journey Hospice use and/or disclose my personal health care  
Autumn Journey Hospice maintains privacy protection and adheres to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). More information on this can be found in our Notice of Privacy Practices.

33.    Do you provide care to clients in nursing homes?

The answer is yes…..in some, but not all, cases. 

Before we explain our answer, you need to be aware of several facts:

  • Title 42, Section 418.24 of the Code of Federal Regulations, gives Medicare clients the right to choose a particular hospice. 
  • Title 42, Section 418.56 of the Code of Federal Regulations requires hospice agencies to establish written working agreements with other healthcare facilities that are jointly involved in client care.  The purpose of this regulation is to ensure that continuity of care is maintained.
  • However, in the case of nursing homes, the Code of Federal Regulations does not require nursing homes to sign working agreements with every hospice agency that residents may wish to use.  Because of this, nursing homes can prevent a resident from using the hospice agency of his/her choice simply by choosing not to sign an agreement with that hospice agency.
  • If your nursing home does not choose to sign a working agreement with the hospice of your choice, you have two options:
    • use one of their “approved” hospice agencies or
    • move to a nursing home that will allow your chosen hospice agency to provide your care.   If you still want to use your chosen hospice agency, then your current nursing home MUST help you find a nursing home that has an agreement with your chosen hospice.  This, however, would require that you move to a different nursing home.

If being able to choose the hospice you want is important to you, you should ask the nursing home if they will allow your chosen hospice to provide service to you.  Since all hospices that are State licensed and Medicare certified provide the same services, you should also ask the nursing home what criteria they use to choose particular hospices and exclude others.

Finally, our answer to the question.  We will be able to provide hospice care to you, if we have a working agreement with your nursing home.  If your nursing home elects not to sign an agreement with us, we will not be able to provide hospice care to you.  If this situation should arise, we recommend you choose a hospice from their list to avoid the potential disruption a relocation could cause.

34.   What are the physical signs of imminent death?

We are often asked to describe the physical signs of imminent death.  As death approaches most people will exhibit many of the signs listed below.  Generally speaking, a person exhibiting a large number of these signs will pass on within two to five days.  However, these are not hard and fast rules. Because each of us is unique, death cannot always be predicted with a high degree of accuracy.

In our minds, death is dependent on three things:
1.  the miracles of modern medicine
2.  the power of the human spirit
3.  the tender mercies of whatever higher power you believe in

Here is our list of the physical signs of imminent death.

  • Hallucinations, or what appear to be hallucinations, may occur.  The person may appear to see or talk to deceased relatives, Jesus or God.
  • The person may become very restless, anxious or agitated with behavior difficult to control.
  • The person may be awake for days.  He or she may be afraid to sleep or to be out of control.
  • The person may be unable to swallow.
  • The person may be unable to enunciate even simple words. He or she may mumble for hours, or days, at a time.
  • The skin becomes very cool, particularly in the arms and legs.
  • The skin may feel clammy and damp.
  • The skin may appear bluish, grayish, purplish, mottled or pasty.
  • There may be a lack of responsiveness to all but very painful stimuli.
  • Pulse and blood pressure may be absent. Heart rate may be very rapid.
  • Decreased movement and loss of strength can be observed and sensation is gradually lost.
  • There may be no purposeful movement.
  • The eyes may roll back in the head.
  • The eyes may appear glassy and fixed.
  • Eyelids may be half or three-quarters closed.
  • Breathing may become noisy due to mucous collecting in the throat. This is what is known as the “death rattle”.
  • Temperature may soar to over 101.
  • The number of times and how deeply the person breathes will lessen until the he or she stops breathing entirely.  Respirations may become rapid and then gradually slow down over hours or even minutes.
  • The person may or may not go into a coma. (He or she continues to hear even while in a coma.)
  • No urinary output for 48 hours or more.
  • Residual air may expelled from the lungs anytime during a period of 1 to 5 minutes after the person stops breathing.
  • To verify that the person has really expired, check he/her pupils.  They will be very dilated and totally unresponsive to stimuli.


1.      Dean Koontz, By The Light Of The Moon (Bantam Books, Random House, 2002);  Prologue


Autumn Journey Hospice
5347 Spring Valley Road
Dallas, TX 75254
Phone: 972.233.0525
Email: wecare@autumnjourneyhospice.com