Why won't my dad's physician put him on hospice?

Igloo572 and others...
My husband was on Hospice and he did get medications for infections.
If I had elected to have surgery, if it was necessary, he would have had to go off Hospice while he was in the hospital but could go back on once he returned home.
the reason he would have to go off Hospice is that it would be double billing through Medicare, hospital billing and Hospice billing and that is "double dipping" of sorts. Thankfully I never had to make that decision, as I would have elected to not do surgery of any kind.
Hospice will not refuse to care for infections or other problems should they arise. What is not done is continue treatment for the life limiting condition that the patient has been diagnosed with.
A cancer patient would discontinue chemo.
Rehab is discontinued as rehabilitation by it's very nature is striving for improvement in a condition.
A person that has been getting dialyses can continue since that is considered a "chronic" condition. At some point the person will probably elect to discontinue dialysis. At that point Hospice will strive for main management.
A person on Hospice, if they fall and break a hip or leg, if surgery is not done the life expectancy is very short mainly due to increased pain but many Hospice patients would not tolerate anesthesia or surgery well at that point anyway.

I think CarreSupport has a good idea - talk to hospice providers and find out the applicable rules, what kind of services your dad might or might not receive. I understand that he does not want amputation - does this mean that he is ready to die?

The staff of the hospice service can explain the regulations to you. In my state a physician must be able to state that the life expectancy is 6 months or less due to a terminal condition. What you describe is not a terminal diagnosis. Call the social worker at your hospice and ask her to help you understand their services.

This is based on the diagnosis and prognosis.

Having a foot that does not heal is probably not on the Medicare list of diagnosis leading the probably death within 6 months. Those are the rules.

If the doctors decide that the patient is not acting in their own self interest...they can require the DPOA make those decisions instead. If no medical power of attorney exists...the doctor and facility can take the decision into their own hands.

The above suggestion is good...also, try grapefruit seed extract, or raw honey. Both have powerful healing abilities.

Have you ever considered taking your father to an iridologist? I took my father, who had many serious issues and he is very healthy now after a year. The commenter who suggested colloidal silver, very good idea.
I hope this helps.

Is your father wanting to go on hospice so that this infection will eventually develop into sepsis and ultimately his death? Is your father wanting to die at home which is why you want to put him on hospice?

Ask the doctor - not the nurse or any other healthcare professional - why he won't put your father on hospice. What is the exact reason. As it stands now, does your father qualify for hospice? Don't let the doctor dismiss you - demand an answer.

You call hospice - now - and go over your father's medical condition. Don't wait for this doctor's answer.

Whoever is POA has every right to challenge a doctor on what the patient wants - and if the patient qualifies for hospice, then POA has the right to move forward with the Hospice medical director for a hospice admission. POA doesn't need permission from the current doctor.

Unfortunately, I've personally witnessed doctors keeping patients hostage so to speak, by running up the insurance for this or that test, dragging their feet to keep the patient hospitalized for as long as possible before insurance says they'll stop paying. Healthcare is very, very money driven...

Hospice changed their requirements a few years back. I agree, call Hospice.

TG, I tried to be conservative to respect my Mom's end-of-life wishes. But when she got a bad foot ulcer it was 8 weekly wound clinic visits with debridement and nurse visits to change dressings several times a week. I put her through this because I didn't want her to have to have an amputation. But her skin started to break down in other areas and soon she had a Stage 4 pressure ulcer on her lower back. Please know she had gentle, professional care. This was her transition. They were not going to heal; no way could she consume enough protein, etc. The choice was hospice or SNF. Even hospice tried aggressively to heal the sores. I had to eventually be my Mom's advocate and say "enough"! I demanded morphine before every dressing and diaper change and stayed by her side for her last 6 days. Sometimes the body is done.

For those suggesting just directly calling a hospice group, for the OP, her dad is in a NH so it's not as simple as this. TGibsons dads is under the care of the existing MD who is the medical director of the NH & whichever MD specialists the NH works with; and in all likihood the NH has a pre-existing relationships with 3 -5 hospice groups that already come into this NH & that residents and their families can choose from for hospice provider.

There are hospice groups at the ready & waiting for medical directors order for a hospice consult for hospice to start. But to me, it's more the case that the MD is reticent to do this cause they know by experience that for a non-compliant patient like dad, the infection will lead to gangrene and then once dads pain gets bad (& it will and be truly awful with gangrene), he's gonna change his mind and now want things (like surgery) done like yesterday..... and if he's on hospice its palliative care only. No surgery, no antibiotics as their "cure".

Hospice can't provide services that cure the Condition or disease. So if I'm correct, any care care that cures his gangrene cannot happen, only comfort care like pain medications. And it's likely to be Schedule 2 black box drug, like fentanyl. A lot of hospice groups do not have staff that carry or administer these for various reasons. Their going to have to work within the hospice groups that already come to this NH. Or she moves her dad into a speciality LTC facility for infectious diseases.

It's difficult situation if her dad is strong willed don't tell me what to do type VS a md who knows pain will eventually cause dad to cave in & allow intervention but could happen too late to remove the infection even with amputations.

Alum is NOT a spice, though according to WikiPedia it can sometimes be FOUND in the spice area of a store (it is used mainly for pickling in recipes, hence WHY you might find it there.)

Per WikiPedia:
"The alums are a class of chemical compounds. Alums are double sulfate salts...

Cosmetic
An alum block sold as an astringent in pharmacies in India (where it is widely
known as Fitkari (Hindi) or Phitkari (Urdu)
Styptic pencils containing aluminium sulfate or potassium aluminium sulfate
are used as astringents to prevent bleeding from small shaving cuts.
Alum may be used in depilatory waxes used for the removal of body hair or
applied to freshly waxed skin as a soothing agent.
In the 1950s, men sporting crewcut or flattop hairstyles sometimes applied
alum to their hair as an alternative to pomade. When the hair dried, it would
stay up all day.
Alum's antiperspirant and antibacterial properties contribute to its traditional
use as an underarm deodorant.

Medicine
Alum is used in the treatment of canker sores in the mouth, as it has a significant
drying effect to the area and reduces the irritation felt at the site.
Alum was the major adjuvant used to increase the efficacy of vaccines, and has
been used since the 1920s. But it has been almost completely replaced by
aluminium hydroxide and aluminium phosphate in commercial vaccines.
Alum has been used to stop bleeding in cases of hemorrhagic cystitis."

For canker sores, sure, this was a known treatment. Given that it is a type of salt, even regular old table salt would help canker sores - they've sold canker sore treatments for ages!! Also note that it is used as an astringent to stop bleeding in MINOR wounds, such as shaving cuts - also a well-known remedy. How do you compare a canker sore or a shaving cut to an open ulcerated gangrenous wound???

Stop spreading nonsense. For this man's affliction, this will not cut it. YOU (and you know who you are) are NOT a doctor and should not spew this kind of garbage. The poster would get just as much benefit from a rhino horn or bear balls or hiring a witch doctor...but be out a lot more money! If the man has a open non-healing gangrenous ulcer, all the alum in the world is not likely to do ANYTHING for him.

Your post also does not address the question being posed.

Recommend poster ask doctor directly, as others have suggested, or get another opinion. If his doctor is just a GP, try finding a specialist who deals with this kind of condition specifically. Asking hospice for evaluation might also be an option.

TG, how are things going? My grandma died of gangrene, from bad toe nail clipping. Come back and let us know what is going on.

Get some Colloidal Silver Gel - it will clean and heal the ulcer.

When my husband was very I'll, our doctor did the same thing. The next morning he died.  I have been told you do not need hospice approval from Dr.  Hospice has their own drs.  Ck it out

It could be that MD does not want dad on hospice as once on hospice it means only palliative care can be done for him at the NH. 

For gangrene, the care plan will likely be debriedement, antibiotics, duoderm adhesives, circulation / movement, etc. and then with amputation surgery as the last resort (my diabetic grandma had gas gangrene started from bad toe nail clipping) but IF he's on hospice & being on hospice means none of these are available (as considered curative not palliative) then hospice placement will be discouraged. This might be why  MD won't do hospice evaluation orders. 

Gangrene if left on it's own will spread rapidly & become beyond painful eventually; and at that point then they agree to surgery only to find out that other organs are too compromised & skin is too necrotic for surgery to be done. It's too late. 

Not all NH are set up for an active infectious disease resident. If your dad is fixed on not accepting MDs care plan & gangrene goes on, ask the NH facility if he will be allowed to continue to stay living there. 

There has been posts in the past on gangrene and the dilemma family finds themselves in. Especially with family member who refuses any thought of amputation. Go up to the search "Q" function type in gangrene and the list of old Q&A will pop up. Lots of solid info with real experience details from BarbBrooklyn, Pamstegman & Vstefans. 

Depending on the severity of the infection, you might consider getting a hold of a spice called alum from your local grocery store where they sell spices. You mix it in warm water and you can actually soak the wound in a pan of the mixture. A dish pan or one of those medical bedside washpans will suffice for this. I wish I only knew about the spice when another elderly friend of mine was living, she lost her leg. I would at least try soaking the wound to see if you can save the limb, you might actually be surprised. The alum has a drying effect on the skin, also the surrounding skin that doesn't have the wound will definitely need moisturized with a real good lotion, just don't get it too close to the wound or even in it. I found out about the spice called alum when I had such a painful canker sore I found myself at the store wondering what to get that would relieve it for what little money I had at the time. That's when I bumped into someone who told me about the spice called alum. I now keep it in the medicine cabinet as a vital necessity in case I need it for other things. You never know when it will come in handy and I highly recommend keeping a bottle of it in your medicine cabinet because it really does work to draw out infections. It also saves money on expensive creams and ointments if you have specific types of wounds that don't really require the use of those expensive first aid creams. Some wounds like the one you're describing actually get infected, and some kinds just require the spice called alum to draw out the infection. I've noticed it working when I feel something like a slight buzzing or vibration in the area as it's starting to draw out the infection. I can't tell you how much money I actually saved using the spice called alum as my first go to for certain types of wounds that just won't heal no other way. I actually had the very early signs of diabetes many years ago when I had wounds that just wouldn't heal. One of them actually had a very deep pocket that kept feeding the wound until I was eventually able to pop and drain it. The reason for these sores not healing is because of the sugar content that was in the Welches grape juice I started drinking, only to eventually get a wound on one of my hands and it just wouldn't heal no matter what I did. After immediately going off the Welches juice (which was loaded with sugar) I was eventually able to get rid of the wound that wouldn't heal and that in part is why I also keep a bottle of alum handy at all times. As much as I couldn't help it, I try to avoid Welches juice since it's loaded with too much sugar that originally caused my problem right after I started drinking it. I bet I was probably on my second or third bottle when my problem started. When I started having problems, I immediately quit Welches and started immediately flushing it out of my system by drinking only water and  nothing else for quite a while and I've had no other issues to this day and it's been around for two decades. I see my doctor regularly and have no history of diabetes because I caught the warning signs early and dealt with it. To this day, I'm very careful of my sugar intake but I discovered I can't quit sugar altogether unless I want to find myself collapsed later from shock. Some people have reported being fine after quitting sugar, but how long can you quit sugar before your body has a sugar shock and you collapse like I did twice? This happens when your sugar gets too low either through diabetes, quitting  sugar altogether or just not getting enough of it in your diet. You can't get too much, but your body does need some so don't go to little either unless you want a sugar shock, I've had two of them in my life and haven't had one since I now keep a healthy sugar level in my blood stream

Doctors generally do not like Hospice...and this is not all doctors..
Because Hospice means that they have failed.
Failed to cure
It may also mean that they will no longer be able to bill for services and that is one revenue stream that will be gone from them.

You do not need your Dad's Doctor to refer him to Hospice. You can call any Hospice and ask for an evaluation. Once Hospice evaluates your Father they will let you know if he qualifies or not.

To find a Hospice ask the staff where he is what Hospice organizations they are familiar with and what ones they think do an outstanding job. Then call the ones that they mention and "interview" them. Or if you know of one that has a good reputation call them.
There are Not for Profit Hospice and For profit Hospice not saying one is better than the other. The one I used, and now volunteer with is a Not for Profit.
You can make the call to Hospice it does not have to be the Doctor.

doctors love money! More often than not elders--especially in nursing homes-- are enormous cash cows for their champagne and caviar lifestyle and in time for Christmas holidays, vacations and expensive presents.  Anybody with a foot that is starting to rot (gangrene) poses dangers such as infection and bleeding to death and it sounds like your dad should be in hospital..or hospice in my opinion.   You may want to tell your dad's doctor you plan to file a complaint against him. Maybe that in itself will save you the trouble of having to actually do it. You definitely are within your rights to file a complaint.   I would like to point out that not all Hospices have to be "Do Not Resuscitate" status but can remain "full-code" if the hospice facility is Medicare approved because it is understood treatment would be palliative.   If you feel your loved one is being mistreated you may file a complaint with your State entities and information is provided by Medicare. See this link. https://www.medicare.gov/NursingHomeCompare/Resources/State-Websites.html ;

Tgibson,

Doctors in general are all about fixing problems and prolonging life. It's crazy and cruel. Has your father talked about wanting to die, given that he doesn't want his foot amputated? How awful for both of you. I'm so sorry.

I am in a somewhat similar position, although it is not as dire. My mom has had breast cancer and a stroke in the past few years. She is now 84 and getting repeated UTIs that have landed her in the hospital 4 times in the last 8 mos. One time she was in septic shock, but came back from the brink. She is wiped out from all of it, but docs are advising surgery on the huge kidney stone at the root of the infections. If you saw her, you'd see that it is totally nuts to put her through surgery. She is not totally with it, so it's my decision.

If a doctor treating my loved one made a decision I found puzzling, I would ask the doctor for an explanation. Not people on an internet forum who know nothing about my loved one or his medical history.

I don't mean to sound snippy, apologies if I do. But seriously, don't be afraid to ask - your question is a perfectly reasonable one and should be addressed to the person who can answer it.

Dear tgibson,

I'm so sorry to hear about your dad's condition. No one wants to see their parent suffer. If you do not agree with the doctor, I would try to seek out a second or third opinion. What other options are there for your dad? They must do something for him to make him more comfortable. Maybe even consider engaging a care manager or social worker to help you.

Hospice is generally for people who are not expected to live more than 6 months. (Obviously no one can predict that for sure, so it is a judgment based on other patients with similar symptoms.) Perhaps his doctor does not feel he is there at this time.

You can ask for an evaluation by the hospice doctor, also.