Insurance Coverage for Hospice?

It seems that all of the current national headlines are about healthcare reform. Even if you are not interested in this topic, you probably know that some 46 million people in this country are without health insurance. Health insurance comes in many forms. The major insurer in this country is Medicare. For people who have worked and received Social Security they also, if disabled or retired, qualify for Medicare.

Most of us who are still working have health care provided in full or part by our employer. Those in the military and their dependents have full coverage and those with past military service may have Veterans Administration healthcare benefits. Health insurance comes in many forms and the coverage may be minimal or complete.

Some of the political and economic debate about healthcare reform is based on the expense of Medicare, the concept of employee benefit through the workplace, or individually owned health insurance policies, and the concept of universal healthcare (which generally means we all, every person, has the same government sponsored insurance and we all get the same healthcare benefit).

How does all of this affect who pays for hospice? Hospice care has been a Medicare benefit since 1983, and since most patients in hospice are over 65-years-old or have been on Social Security disability, Medicare pays most of the hospice bills across the country. Private health insurance usually focuses on cure, recovery, and rehabilitation. Some insurance companies are now starting to understand the importance of hospice, and that hospice can be a benefit of many private healthcare policies. Tricare and VA help those with present and past military service. Medicaid, on the state level, may assist those who qualify.

Probably the most important concept for hospice is the concept of compassionate care at the end of life. This care is not only meant to be sensitive and supportive to the patient and family in terms of medical care, it is meant to identify burdens and stresses in the patient’s life and help diminish them. One major stress may be the worry a patient or their family has about paying for hospice services.

Medicare, private insurance, Medicaid, Tricare and veterans benefits may pay for hospice services. Most hospices practice compassion in accepting all patients who need their services, not just the ones who can pay for it. So, in the final analysis, insurance coverage is not required by most hospices.

My recommendation would be, if you or someone you care about might need hospice services, ask right up front about insurance and pay requirements or restrictions. The patient and their family are the customer and as the customer they can pick and choose that hospice that represents the highest quality and can provide them service based on their need, not their ability to pay.

~ Dr. Leonard Hock

Hope

Hope. When it comes to our health “hope” is a very strong and even intense word. For minor illnesses we hope we get over them soon. For chronic, long term medical conditions, like high blood pressure, diabetes, and arthritis we hope to control them. We hope the patient can follow the doctor’s orders and have a good quality of life. For life threatening diseases like cancer, strokes, serious heart attacks, we hope the patient can fight the disease and beat it. Generally we hope that the patient can have a cure and not die.

That kind of hope along with support and perhaps mixed with prayer can make a world of difference in a patient’s life. They know that they are important. They know that they are being cared for and being cared about. That kind of hope often gives the patient the emotional support to be brave and courageous in the face of serious disease or difficult treatment. Hope, when realized, along with good medical treatment and lots of support may mean that the disease is cured. Or medical conditions are controlled and the patient, the person we are hoping for, can live a long life that is also filled with quality.

Sometimes our hopes are not answered and disease shortens life. Even when our hopes are answered life is not endless. Now theologians and spiritual leaders may say that life is endless and that we can experience immortality. Well I’ll leave that to your own personal faith. But we can all agree that in our present body we will come to the end of our life. For ninety percent of us, those of us who don’t die very suddenly, we may have an opportunity actually to see before us into the future the last days, weeks, or months of our lives. When our days are numbered or our weeks or months are numbered and whether we are very old and a cure was effective or whether we are still young and the cure was not effective how can we anticipate the end of our life, understand it, plan for it, and still nurture the most quality for whatever time we have left.

For decades now hospice has focused on exactly this issue. When life is limited the quality of life does not automatically have to be limited. Hospice provides care and compassion when curing a disease is no longer possible. Hospice is not a place to give up… it is a place to live up. Live up to our maximum potential for as long as we possibly can. With symptoms controlled, individuality respected, and family supported, hospice focuses on life.

In hospice when a cure is no longer possible, care is always possible.

~ Dr. Leonard Hock

Hospice or Home Health?

Home is where the heart is. Home sweet home. There’s no place like home. We do love our homes and for almost all of us, there is no place we would rather be. Our homes are an extension of ourselves. We find comfort there and hopefully we find love and peace in our homes. When we are away from our homes some of us even develop an illness. It happens to people in the military, in college students, in business people who are often away from their homes. We call this illness “homesick”. It doesn’t really matter where we are, if we aren’t home, we miss it and long to be there.

When, however, we really get sick with an accident or a serious medical condition the hospital is where we receive our medical care. In the hospital we have specialists, technicians, nurses and therapists that can help us through the surgery, illness or the serious medical condition. We all appreciate the high level of quality health care that is provided in a hospital. However, when we start to recover or even get just a little bit better most of us want to go home.

At home, to continue our recovery after a hospitalization there are three options of care. One option is friends and family. If the illness or injury wasn’t too serious, if our hospitalization wasn’t complicated, and if our health is improving our friends and family may give us the support with daily activities, errands, and simple tasks that we need to improve our health.

The second option is home health agencies. Home health agencies provide skilled nurses and aides, social workers, and support for a longer recovery period that may include rehabilitation and perhaps other special care like post surgical dressing changes or special nutrition support. Home health agencies exist in every community whether a large city or a small farm community.

In the last several years Medicare has changed home health from a nearly pure care giving situation to a combination of care giving and education. Now days to qualify as a home health patient there must be identified a healthy, able, caregiver in the home. A husband, a wife, a son, a daughter, or even a good friend who can commit themselves to the education that the home health agency gives them so that they, not just the nurses, the aides, or the other home health staff can provide care but that private individual will be responsible for the majority of the care for the patient. For those patients who are receiving Social Security Medicare usually covers the cost of the home health agency care.

The third option is hospice care. Immediately hospice care sounds like the end of life care, and it is, but it isn’t about the very end of life. It’s not about the last hours or days of life. Hospice care is a Medicare benefit and for those patients who may have a life limiting illness, not limited to days but perhaps weeks, even months, even several months at that, hospice care provides all of the benefits of friends and family care, all of the benefits of home health agency care, plus volunteers, chaplains, social workers, grief counselors and specialized doctors as well as the nurses and hospice aides that provide such wonderful, compassionate care.

It is very hard to think about hospice care because that does mean end of life care. Even if it’s the last five or six months of life, most people don’t want to think about letting go or “giving up.” However, hospice care can absolutely be the most appropriate care. If someone, a patient, needs to go to the hospital for an illness or a surgery and they can completely recover they don’t need hospice care or probably don’t even need home health care.

If their goal is after a hospitalization or a serious illness to rehabilitate and recover then home health agency care would be the best option. But sometimes, and eventually, for all of us we will have a medical condition or an illness from which we cannot recover (we are not immortal on this earth). For patients who have tried their best to recover from illness, those who have used all of the strength possible to rehabilitate back to a healthy state, who have given everything they’ve got to get well but do not and it is finally realized by the patient and their family that they have come to a place in their life where more hospitalizations, more physical therapy, more medications will not improve their life then at home (home sweet home) hospice care may be the best option of all.

~ Dr. Leonard Hock

The Fear of Dying

Life is good.  It’s not just a logo on a t-shirt.  Life really is good.  Ask anyone and you will get all sorts of positive responses.  As one of my medical school professors once said “it is widely held and deeply rooted that living is better than dying.”

On any day, even a bad day, you can probably name some wonderful things that are happening in your life—the garden is growing, the kids are doing well, payday is coming up, or “I’m just glad to be alive.”  If life is good then dying must be bad.  They are opposites.  If death meant only the absence of life, that would be bad enough alone.  

Death is a mystery.  For most of us, based on our faith, death is eternal nothingness or eternal heaven or hell.  However, death and dying is more than just the absence of living.  We know that about 10% of people who die do so suddenly and unexpectedly.  They don’t have a chance to look at their dying process. 

While the rest, about 90%, have an illness or a medical condition that will eventually take their life.  They have time to look forward at not only their death but the dying process as well.  With dying, comes the fears that most people share.  The fear of dying with pain or suffering.  The fear of dying alone, isolated and lonely.  The fear of dying in a place that is cold, sterile, and uncomfortable like an intensive care unit.  There may be other fears related to family dynamics or financial issues.  Perhaps individual fears based on faith and religious concepts.

At hospice we understand these fears.  Even though every individual may have their own doubts, fears, and concerns most of the fears are commonly shared with patients who are nearing the end of their life.  In fact, when hospice patients are asked their three top wishes we find that their wishes are directly related to their fears of dying. 

In surveys the number one wish is to have pain control.  Patients have a fear of pain and suffering and they wish to have their suffering controlled.  The number two wish is to be in the company of their friends and families.  Patients do not want to die alone.  They want companionship and they want humanity surrounding them so they feel the comfort of love and support.  The number three wish is commonly stated as “I want to die at home.”  Most folks who are facing the end of their life want to be surrounded by their belongings, their favorite chair, their TV programs, their books and music.  Hospice understands how the fears of dying and the wishes for comfort, family, and home go together.

Eventually for all of us mortals, no matter how wonderful the medical care is, we will all come to the end of life.  Medical professionals can’t stop the dying, but hospice can certainly comfort the fears associated with it.

~ Dr. Leonard Hock

What About My Family?

As you can imagine when someone is diagnosed with a terminal illness or a medical condition that has finally brought them near the end of their life, the focus of hospice care is on the patient. Friends and family wish that the patient could live as long as possible. The hospice doctors want to be sure the symptoms of pain and physical distress are completely controlled. The hospice social workers, nurses, aides, and chaplain pay attention to the patient’s needs, comfort, and peace.

When faced with our own mortality our minds race. We think about a thousand things all at once. We have fears, anxieties, stresses. The desire for hope and a sense of loss even at the same time. Most patients are very, very relieved that hospice is there to comfort them, support them, and improve the quality of each and every day.

We in hospice know that most patients who come into our care have hundreds of questions and we try to answer each and every one of them. One question that comes up time and time again “Doc, I know you all are taking care of me, but what about my family?” We see many, many instances where the patient worries more about their family than they do about themselves. The mother who is dying of breast cancer worries about her teenage children “what will they do without me?” The grandfather whose pension and Social Security check still support members of his family “how will they get along when I am gone?” The grandmother who worries about worrying “I do have pain but I don’t want my family to know. I just don’t want them to worry about me.”

These are real people with real concerns. Their thoughts of their family affect their quality of life. That’s why hospice never separates the patient from their family and the ones they love. Hospice doesn’t physically separate them. No, we take care of patients in their home so their family can be there. Or in the nursing home with no set visiting hours. We have inpatient units that are home-like so that members of the family can be with the patient around the clock.

We don’t separate the patient from their family even with our care. In fact, when the nurses and the care team are developing a plan of care they take in to account the loved ones, the family members, the family dynamics so that the family is involved in the care of the patient and the hospice is also caring for the family.

And, at hospice we don’t separate the patient from their family in our hearts. In fact, the language that we use is patient and family. We talk about, we think about and we care about the patient and family as one unit. We know that every patient is an individual and every family and all of the relationships in it are unique. That’s why chaplains, social workers, and all members of the hospice team direct care toward the patient and the family. At hospice we can control the pain, the shortness of breath, the fear, depression, and anxiety. But we understand that no one wants to be alone at the end of their life. And it’s the family that provides love, companionship and that wonderful, special sense of meaning.

Hospice takes into account that young mother who is going to leave teenage children. They take in to account that grandfather whose retirement and Social Security supports the family. We understand that a grandmother may not want to worry her family and with that understanding hospice can provide care and resources, options and choices that help every patient in hospice answer the question “what about my family?”

~ Dr. Leonard Hock

Why Hospice?

Since the beginning of mankind death has been a certainty. In fact, death is an absolute certainty. We all, everyone of us, will die. For as long as man has existed death has existed. But hospice as we know it today has only been around for the last forty years or so. For thousands and thousands of years we’ve been able to die without the help or support of hospice. So why now in the last forty or fifty years would any of us need hospice? We can certainly die without hospice, it’s always been that way. So, why hospice?

Hospice, in its philosophy of human kindness and comfort, has been around for as long as human beings have been kind and compassionate to other human beings. Florence Nightingale comforted dying soldiers on the battlefield. Mother Theresa comforted the sick and dying in Calcutta, India. The concept of comfort at the end of life is as much human nature as a sense of kindness and compassion. So, why hospice?

Hospice is organized kindness and compassion. The hospice doctors and nurses focus on relieving terrible symptoms like pain, fear, and anxiety. The hospice aides, social workers, chaplains, and volunteers bring comfort, respect, and dignity along with care. The grief counselors, bereavement staff, support the patient and the family during a time of stress, depression, sadness, and loss.

Hospice volunteers and staff provide company and human contact with those patients who would otherwise be alone at the end of their lives. Hospice chaplains provide a sensitive and listening ear and when requested provide spiritual support to the patient and family.

If a person was coming to the end of their life without pain or distress, without physical suffering, emotional loss and sadness, with their faith and spirituality completely supported, with loving family surrounding them, a family who is secure in their emotions, handling the stress of death without the need of any strong shoulder to lean on, then that patient and family might not need hospice. However, in my 30 plus years of experience as a physician, it’s the rare dying patient who has no pain and no symptoms.

It’s the rare patient who can die strong when they die alone. It would be the rarest of families who are not moved in a deep and heartfelt way at the loss of a loved one. In fact, it is so rare that I’ve never seen such a patient or family. All of us as human beings have some suffering– emotional, spiritual or physical suffering as we near the end of our life. Our families are grieved at the sense of losing someone they love. That human nature, that physical suffering, that aloneness is exactly why hospice. Hospice tends to not only the physical condition but also to human nature.

For thousands and thousands of years mankind has experienced death when there was no hospice, but now there is hospice. Hospice is available to all of those who are coming near the end of their life. Hospice is specialty care for a special time of life. So now that hospice is available the question I would ask is, “why not hospice?”

~ Dr. Leonard Hock

What Hospice Means for a Family

Hospice provides care and support to the patient and the patient’s family near the end of life.  The “and family” is a very important concept in hospice.  When anyone has a terminal disease or a medical condition that brings them near the end of their life it is not only the patient who suffers it is also the family.  

In fact, some studies and many observations have shown that the patient can understand their illness, can work through the emotions that happen with such news and actually become somewhat accepting of the natural events that are bringing them to the end of their life.  But it is the family who doesn’t want to let go, who is incredibly sad, who feels the pain of loss and separation, who often have a very difficult time with the end of life events.  Hospice focuses on the patient and includes the family in terms of care, support, and compassion.

Have you ever expected one thing and experienced another?  Like going to a family reunion and expecting your crazy uncle to stir up everyone.  When, in fact, he turned out to be calm, polite, and even fun.  How about tasting vegetables, you expected not to like them and you experienced a flavorful, good taste.  You might try them again.  Or have you ever ordered anything from the TV shopping channel or on the internet and you expected to get a wonderful, high quality item when, in fact, you opened the package and found it wasn’t at all what you expected? 

I think we’ve all had these or other experiences when our expectations turned out not to be what we really experienced.  With hospice it’s all about end of life care, we expect anything to do with end of life to be sad, morbid, serious and depressing.  The expectation may be that any conversation from the hospice doctors, nurses, and staff will be about death, giving up or loss. 

When, in fact, the experience is likely to differ from the expectation.  Hospice does care for patients and families as the patient nears death.  But the focus is on life.  Hospice seeks to comfort pain, relieve suffering, and look at the joy of life “everyday is a gift.”  Hospice is there to talk about frank and honest conversations that the patients and families wish to talk about.  However, hospice is also there to be sure that everyday of life is the best day it can possibly be. 

The basics of supporting life are to relieve and diminish the pain and suffering, but beyond that, at another level hospice seeks to actually improve the quality of life for the patient and the family.  Improve that quality of life by doing things that the patient and family especially love to do.  Like a day fishing or a day at the ballpark or a trip to a family reunion, to interact with that crazy uncle. 

Hospice volunteers are wonderful at improving the quality of life for everyday folks living their everyday lives because they are individuals with love in their heart and importance to their family.  Hospice aides provide cleanliness, friendship, dignity, and personal service to the patient and family.  Chaplains, social workers, grief counselors and bereavement staff provide the support that families and patients seek and ask for.  While the doctors and nurses are there to evaluate, assess, and comfort the patient with treatments, therapies, and necessary medications.

So the expectations of a family may be that hospice is all about “doom and gloom” when, in fact, the common experience is that hospice is about comfort, quality of life, and hope.  Hospice cannot put more days into life, but hospice can put more life into days. 

~ Dr. Leonard Hock

Can My Doctor Provide Hospice Care?

The short answer is yes, of course but now days no answer could be quite that simple.  Family doctors, internists, geriatricians, even pediatricians, specialists like surgeons, and cancer specialists can all provide hospice care.

Doctors who know their patients very well may know hospice care only to a limited degree.  Oh, doctors, any doctors, understand that hospice care is comfort care and symptom control near the end of life.  Most doctors, whether they know much about hospice or not, seem to understand that comfort and compassion are the foundation principles of hospice care.  Therefore, doctors certainly can provide comfort.  Most doctors understand how to relieve pain, calm anxiety, improve depression, and provide compassion to their patients.

Doctors are confident professionals and frequently I am told that doctors don’t need a hospice organization to provide hospice care.  They explain to me that hospice is not only an organization of doctors and nurses but rather hospice is a philosophy of care.  A philosophy that embraces acceptance of a life limiting illness or disease, a philosophy that focuses on comfort and compassion, and therefore any doctor can embrace the hospice philosophy.  And, I have to agree with them. 

Hospice is absolutely a philosophy of care.  It’s a philosophy of embracing the patient and family.  Not the test.  Not the x-ray results.  Not a new medication.  But focuses absolutely and completely on the patient and family needs.  The patient’s need to cope with their illness and disease.  The family’s need to support someone they love.  The patient’s need for symptoms control, pain management, and attention to depression and loss.  But what the hospice organization has that the philosophy alone does not is people. 

We’ve got people.  We’ve got people with the philosophy, we embrace and endorse that philosophy that family doctors and cancer doctors speak of.  But with that philosophy we’ve added people.  We’ve added doctors and nurses and hospice aides to give a gentle bath.  We’ve added chaplains, not to preach, but to listen and support the patient and their family with whatever their personal needs and their spiritual needs might be. 

We’ve got social workers who want to understand the patient as a person, where are they in their life because after all it’s life that’s important not just the dying.  Social workers focus on supporting and family with whatever their needs might be.  Grief counselors and bereavement specialists are there because any terminal illness comes with a sense of loss—often despair, anxiety, stress, fear, and depression.  They are hands on, heart on doctors who care about the patients and families they serve.

So doctors who know the hospice philosophy but don’t understand the hospice organization fully can provide connected care, compassionate care, and comfort care but only as one physician.  When they use that wonderful hospice philosophy and join it to a hospice organization now that family doctor, that internist, that geriatrician or cancer specialist can connect their own personal philosophy to the hospice people that can join with the family and loved ones to provide the care and support that any patient with life limiting illness deserves.

~ Dr. Leonard Hock

Where’s the catch?

When something sounds too good to be true, it probably is.  You’ve heard that and many other famous statements that should cause us to be suspicious about an offering that sounds too good to be true.  “The devil is in the details” and “it’s all in the fine print” are just a couple of expressions that we use when the deal just doesn’t sound exactly right.

 

Hospice, the kind of healthcare offered to patients and their families who are facing the end of their life, may sound too good to be true.  Hospice offers doctors and nurses who are specialists, hospice nurse aides, chaplains, volunteers, grief counselors, social workers, and other healthcare providers so that the highest quality care can be delivered. 

 

There’s no catch, high quality care is the goal.  The right amount of specialty care, the right amount of compassion, the right number of people on the hospice interdisciplinary team, the right kind of dignity bestowed on the patient and their loved ones.  More and more people are turning to hospice. 

 

Although we all want to live as long as we can and we certainly want the people we love to have all the medical care they need and to have the long life that we want for them, it is an absolute fact that on this earth we will all come to the end of our lives.  It seems that more people understand that.  They also understand that at that difficult and stressful time of life there are healthcare specialists, hospice, who can always do something.  Something to control the suffering.  Something to respect that person as an individual.  Something to be there for the family.  Hospice can be the right care, the best care for a patient with a life limiting illness.  So, where’s the catch? 

 

Maybe the catch is the cost.  Who pays for hospice?  If the care is specialty care and delivered by doctors, nurses, and the whole team, then it must be expensive care.  And if it’s expensive who’s going to pay for it?  Is hospice care only for the wealthy, the well-to-do who can afford any kind of healthcare?  Is hospice only for the well insured, those people who have a great health insurance benefit plan?  The answer is hospice should be and can be for any person who has the need.  Hospice should be and in most areas can be for any person facing life limiting illness regardless of their ability to pay. 

 

In the early 1980s Medicare recognized hospice as a very valuable health service.  So, there is a Medicare hospice benefit.  Some insurance companies caught on and provided a hospice benefit.  Not long after that the Veteran’s Administration understood that hospice was so valuable to their clients, ex service men and women, that hospice became a veteran’s benefit. 

 

So, Medicare got it, insurance companies got it, the Veteran’s Administration got it, and then hospice got it.  It’s not all about hospice coverage, it’s about the hospice need.  So, many hospice organizations in this country have an “open access policy”.  That means that although they must budget as a business so they can pay their bills and salaries hospice organizations realize that the service they provide is so valuable it should not be denied anyone who needs it.  If, near the end of life, a person and their family has suffering—any kind of suffering—pain, shortness of breath, depression, anxiety, hospice can be there to provide the medical care and comfort that is needed.  Where’s the catch? 

 

Well, believe it or not there isn’t a catch.  Quality care by specialists—doctors, nurses, chaplains, social workers, and aides supported by Medicare, the VA, many insurance companies and supported by the hospice philosophy that no one should suffer at the end of their life.  Hospice should be there for them.

 

~ Dr. Leonard Hock

“I’m not a doctor, but…”

As a hospice doctor I often have people tell me “I’m not a doctor, but…”  By that statement I think they are trying to make two points.  First, that they have an idea or opinion about a disease, a healthcare issue, their own health, or someone else’s medical condition.  Second, that although they are committed to their opinion, they don’t have the training or experience of a doctor and therefore are not an expert.

 

I often smile sometimes to myself internally when I hear that phrase because I know that  you do not have to be a doctor to recognize a sick person or to be aware of an illness or to realize that a person is suffering.  A mother knows when her child isn’t feeling well, a wife knows when her husband is just not himself, an adult daughter can sense the suffering of her frail, elderly mother.

 

Several years ago I was caring for a very sweet, elderly lady with Alzheimer’s who became suddenly ill and was transferred from the nursing home to the hospital emergency room.  I had discussed the patient’s condition with her daughter previously and we both understood that this very old, very frail lady was beginning to have more medical problems more frequently and that she was likely beginning the final phase of her life.  Even though we had that discussion, in the emergency room the doctors and nurses there recognized a very sick lady.  She was then transferred to the intensive care unit, started on a mechanical ventilator, IV fluids, and heart meds were started. 

 

Antibiotics were given and the patient laid there for several days with little decline and no improvement.  Each and every day her daughter would sit by her bedside as long as the intensive care nurses would allow and every day I would discuss the patient’s stable, but non-improved, condition. 

 

Finally, after a week it seemed clear to me as the attending physician that the patient, in spite of all aggressive and heroic care in the intensive care unit, was not getting better and would never improve.  Based on that knowledge I began to rehearse the conversation I would have with her daughter about the end of her mother’s life and that we should consider comfort measures and hospice care instead of continuing ICU care that was not helping. 

 

I entered the patient’s room and there was the daughter sitting quietly and dutifully at her bedside.  I examined the patient, studied the IV labels, looked at the breathing machine, and checked out the heart monitor.  I examined the patient again and then I turned to the daughter and said “I don’t think she is going to get better.”  The daughter’s head lifted, her eyes brightened, and she said “Finally somebody besides me sees what’s happening to my mother.” 

 

It occurred to me at that moment that you don’t have to be a doctor to see the facts.  In fact, it was a non-physician who understood clearly that her mother, this patient, was not going to get better.  She had come to a natural and expected place in her life where decline was expected.

 

The patient’s daughter and I, at that moment, were on the same page.  We were having the correct conversation about care, quality of life, and comfort.  The problem had been the daughter was there long before the physicians were on that page.  That day I learned an important lesson taught to me by someone who was not a doctor but someone who clearly understood the situation. 

 

Now days I often hear the comment “I’m no doctor, but….” and I immediately let that person know “you may not be a doctor but you may very well know exactly what you are talking about.  So, please, let me hear it.”  As a hospice doctor friends and family often recognize loved ones who are failing, who are very ill and not getting well, who are suffering and they may want to contact hospice but they hesitate because they aren’t a physician. 

 

Even patients realize themselves that their medical condition or disease is progressing and what they really want out of life is comfort, companionship and the kind of care that will remove suffering.  But they may not realize that they don’t have to be a doctor to start the hospice process.  Anyone who cares about a patient, a family member, a friend, a neighbor, or the patient themselves can contact hospice. 

Hospices have trained professionals, sometimes referred to as the intake or admission staff, who accept those calls and inquiries and assist with the whole process.  Sure, doctors and nurses will get involved.  So will social workers, hospice nurses aides, and others who can help but when it comes to contacting hospice about the care of a patient anyone can make that inquiry.  You don’t have to be a doctor.