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My mom is 89. Very frail and weak with some dementia going on. She has been diagnosed with end stage congestive heart failure. She also has afib. She has four leaking heart valves and angina. She was on warfarin for years and her cardiologist recently switched her to Eliquis in the last few months. (blood thinner to prevent clot and a stroke). My mother just enrolled in hospice so it is an adjustment from shifting focus from keeping her alive to just keeping her comfortable for however long she has left. The goal I'm told of hospice is not to hasten death but to just give her better quality of life and manage her symptoms for as long as she has left. I'm confused though. The hospice nurse on her first visit today suggests that we discontinue her Eliquis. By discontinuing this blood thinner doesn't that increase her risk of stroke and thus an earlier death? Wouldn't that "hasten" her death? Wouldn't a stroke make her MORE uncomfortable??? I'm just really confused. Thoughts???


Also I have one more question for anyone who has had experience with congestive heart failure patients. How will I know when the end is near? My mom is ambulatory but BARELY. She falls several times a day. Because of the dementia she is up roaming around a lot through the night and thats when she falls. She will use her walker but after a few steps puts it aside and continues on her own weaving and wobbling with each step. She is very slow and very unsteady and very weak. I'd say within a couple months she'll be bed bound. Sometimes she is very lucid. Other times out of it. She is currently in afib. She eats very little. Communication is hard because not only does she not understand a lot or retain what you tell her but she is almost completely deaf now. At her last pcp visit a couple weeks ago he said she was definitely eligible for hospice (which we are on now) and that she is end stage and terminal.

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This is interesting because someone just asked about discontinuing Lasix and when I searched one of the medications (or class of medications) that is generally discontinued are blood thinners.
Side note though if she is falling several times a day I would question the use of blood thinners anyway. I think there is a higher risk of bleeding than risk of stroke or clot.
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Experienced healthcare professional and hospice professional here- I had to respond because there is a lot of information in these answers and it varies in what is true, versus what is opinion presented as true and what is false.

I wanted to give you very clear guidelines so that you or anyone else with a similar situation understood more about hospice.

First, hospice is paid for primarily by Medicare. Medicare has guidelines that every hospice must operate under and that individual hospice interprets the Medicare guidelines for their agency. So what that means is one hospice may read the Medicare guideline of a patient with a dementia diagnosis and determine the patient is not eligible for services and another hospice may read the same guideline, evaluate the same patient and determine that the patient is eligible. Simply put, there are variations between hospices.

This leads me now to medications- Medicare requires that the hospice agency provide for the all needs related to the care and treatment of that patient, which includes medications, supplies and equipment. Hospice providers do not also have pharmacies, medical supply companies and DMEs, so they must contract with those vendors. Those contracts state what the vendors will and won’t provide to the hospice agency- and sometimes, for whatever reason, things like specific medications aren’t on that list- so the hospice agency can’t supply it to the patient. The hospice agency can also decide, based on how they interpret the guideline, as to whether they will keep the patient on their medications or discontinue their medications, change them to a cheaper medication to save on their pharmacy bill, stop a medication completely because they deem it to no longer be necessary- and all of these decisions can be within that hospice agency’s realm to make. This is why you will have some people say the hospice made them stop all their medications or the hospice required them to use a generic brand for their medication.

This brings me my last and final point- a good and reputable hospice is in hospice because they see the beauty in caring for people at the end of their lives. A good and reputable hospice has nurses who want to make their patients as comfortable as possible and will advocate on behalf of those patients. A good and reputable hospice will be able to explain to you and would want to explain to you why they are suggesting stopping a medication, or for some of the other posters, why your loved one passed away so quickly on hospice. (Often times it is because the rest of the healthcare system didn’t prepare you or the patient for what was really occurring). A good and reputable hospice can tell you their interpretation of the Medicare guidelines and if you don’t like how it is being applied, then there are other hospices who may have a different response.

I hope this helps. Also, for what it is worth, I do not think Eliquis is a good medication for an elderly person who falls frequently. I also wouldn’t recommend starting Warfarin instead.

Thank you for allowing me to be a part of this conversation.
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MACinCT Dec 2022
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In my experience ..whole point of hospice care was indeed to hasten death..load her up with sedating meds so couldn’t even spend time she had left with any semblance of actual life.
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Hospice hastens death.
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Hospice hastens death. Don’t let anyone tell you otherwise.

My brother had congestive heart failure and was screened and admitted to hospice in an inpatient hospice setting subsequent to a hospitalization. Like your mother, he was ambulatory but barely. He went home for four or five weeks with in home hospice services and then he got a UTI. When he was readmitted to the inpatient hospice facility, I do not believe they treated the UTI and instead pumped him full of knockout drugs until he completely lost consciousness and died after five or six days. I believe they took him off his opioid pain meds so he became belligerent, which was his normal personality until his orthopedist found a “magic bullet” drug to help control his excruciating back pain about a year before he died. It was expensive but he became a different person after his normal treating physician prescribed it. After two days, the hospice personnel reported that he had become hostile and aggressive. I guess the drug he was on when he was admitted was incompatible with the drugs they were using to provide so called “comfort care,” so it isn’t surprising that his normal oppositional personality re-emerged. He fought death every step of the way, flailing his arms when visitors came even though he was almost comatose because of the drugs they were using to control him.

I will never feel comfortable about what they did but I was not in charge. I do not believe my brother died a natural death. I believe very strongly that he would still be alive today if he had not been enrolled in hospice. My brother was totally lucid, had an excellent memory for recent and remote events and could have lived another five years if someone had been living in his home to care for him. After his wife died, he lived by himself because he could not afford to do otherwise. There was no one available to care for him and he refused to go to a nursing home under any circumstances. With his destroyed body but active mind, he would not have fit in anyway though he desperately needed physical care. The experience of his illness and death was a lesson in the complete inadequacy of the American health care delivery system for people who do not have substantial resources in old age and no long term care insurance. This forum is a rich repository of stories about America’s unwillingness to look after its dependent elderly citizens. Services for dependent children are no better.

Lots of people are eligible for hospice but their families do not enroll them until
thry are truly at the end of life. Using hospice as a substitute or supplement for hands on care at home or in a facility is a recipe for a premature death. If you want your mother to be treated, dis-enroll her from hospice immediately. They do not prescribe or refill drugs that prolong life. Re-enroll her when you are certain she is at death’s door. Ask yourself how you would wish to be treated if you were in your mother’s shoes. Keep in mind always that some day your mother will be you.
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When mother was on hospice, the only meds she was given was the pain meds. All her other 9 meds including blood thinners were discontinued. I was told Hospice means making sure someone is comfortable for end of life and therefore medications which 'improve' quality of life, are not given. Pallative care, on the other hand, does provide all the meds one typically takes because they are working on getting 'better' health wise.
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Since mom falls frequently, Eliquis puts her at risk of nasty bruises and hemorrhages with every fall; that would hasten her death. Congestive heart failure is not managed with Eliquis but through diuretics, managing diet and fluid intake, and heart medications to help heart function more efficiently. People with Afib usually get some form of anticoagulant to avoid blood clot formations. Talk with her doctor about her taking baby aspirin (81 mg) daily to prevent blood clots. Aspirin at that level is less of a danger for hemorrhages. Also consider putting thick gym mats on either side of her bed, removing bedside tables, and clearing rooms of tripping obstacles since she tends to fall but needs protection from injuring herself when she falls.
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msfaithk906: Perhaps the reason for the recommendation to remove the blood thinner from your mother's regimen is due to her fall ratio/"several times a day."
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You might want to ask the Hospice people who the best and most attentive doctor is in your area. Also, look for Geriatric specialists.
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Because she's enrolled in Hospice. If she were on Palliative care, they would continue the medications. When my Aunt was forced into Hospice by my sisters, the doctor withdrew all medications and only prescribed morphine. She was dead in a few days.
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This chapter is coming to an end and Mom is slowly disappearing, whether you're ready or not. Hospice, doesn't offer hope, rather it is about letting go with mercy.

Accept the last PCP's information as your last opportunity to hold her hand and say the words you feel, even if she can't hear them: she will feel them.

Blessings to you and mom. If she has a DVD player, you can run soft and gentle movies for her..............perhaps nature films of Yosemite and other beautiful spots.

https://stacker.com/stories/3362/30-best-nature-documentaries-all-time
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Discuss her medications with her doctor and ask your questions to the doctor. One possibility: there may be side effects to the medications that are no longer worth the benefits. When my mother went into hospice, the doctor discontinued some of her medications that were designed to "fix" things. She ended up living more than a year on hospice and with more stable health while taking fewer medications. Regarding the falling, we also put my mother on a "no hospitalization" directive when she went into hospice. She also was falling often, and the facility had to call EMS every time to assess her. Occasionally they'd send her to the hospital. She hated the hospital and didn't understand what they were doing. It was stressing her out. My mother also transitioned to "soft foods" and eventually had to be fed. The hospice workers will also be a source of information. You can discuss your questions with them.
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Except for the dementia, my mother died from this exact thing. She had rheumatic heart disease which led to an enlarged heart, 3 valve replacements, 1 valve repair, congestive heart failure, afib, angina, and more.

Ask her cardiologist about discontinuing Eliquis. My mom was on warfarin (Eliquis wasn't around) because of her artificial valves. I don't recall if he discontinued warfarin as she neared the end. Eliquis & warfarin work on different phases/areas of the clotting mechanism in the blood. The irregular heartbeat could create an environment for a clot, but that doesn't guarantee she'll get one. Falling probably makes her a better candidate for bleeding. There are now medications to reverse the bleeding effect from Eliquis; however, her age, condition & hospice protocol could preclude that intervention.

There will come a time when your mother will not have the strength to get out of bed. In one way, that could be a blessing, as you will no longer have to worry about her falling. But the congestive heart failure will make breathing difficult. That was the most difficult for me to deal with. By that time, it's unlikely she will be very responsive.

My mom was in hospice in a hospital, under an oxygen tent with an oxygen mask. Her breathing was labored and congested. The nurse suggested morphine, but I didn't want to do that because I mistakenly thought it would hasten her death - foolish me, she was dying with or without morphine. After a short while, I agreed to a small dose. The change was dramatic: no more congested breathing. She continued to get doses as needed and died the next day.

My mom was 1 month shy of her 88th birthday. No one expected her to live that long - she was close to death when she was 65, but life saving surgery at the Texas Heart Institute gave her an extra 22 years. She lived with me for many years. We didn't always get along, but I wouldn't exchange those years with her for anything. I'm so sorry that you have the added complication of dementia, and I wish you well as you travel this difficult journey.
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I recently put my mom (92) on hospice at her assisted living facility. They have not stopped any regular meds. She has CHF, COPD and a whole host of other issues.

As mom gets agitated quite a bit lately, they give her Atavan. Because she is having a hard time breathing, they now have her on breathing treatments, but when she is really struggling with breathing, they will give her Morphine which helps the pain and the breathing.

Oh...mom is pretty deaf and her vision is pretty bad.

I know there are many reasons to put someone on hospice and each reason might have a different plan. I am so happy with the hospice care plan my mom has.
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A hospice Dr and a regular GP look at patients in different ways.

QAULITY of life vs. QUANTITY of life.

Once she has left the care of the GP, the hospice doc takes over. I know my dad went from taking 4-5 meds daily to only having meds for comfort. My mom still mashed up his cholesterol drugs and put them in pudding. I caught her doing this and for some reason she felt that this particular drug was still VERY important. We had to literally take away all the old meds and let the comfort meds be the only thing he took. I remember saying to her "why would you want to put him through a single DAY of the misery he's in?" She had no answer--just hadn't accepted the reality of the situation.
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You answered what I was going to ask. First though, your Mom is very lucky to have someone so concerned for her well being. The question was going to be does your Mom fall and then I would ask about Dementia. Your Mom is at the end of her life. Dementia patient's are difficult to give meds to at the best of times. Usually end of life care is just comfort care only. So pain medications. Other meds are almost always discontinued. The goal being a good death, not prolonging life. I assume that is what you are hoping to achieve in hospice. The other notable thing you mentioned is your mom is falling several times a day. Likely the risk with blood thinners and falls is very high at this point. (head bleeds). Your Mom's health care team will have all the information to make the right choices and suggestions for your Mom. No one knows when it will be the end.
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As a pharmacist and a lawyer- and a person who has taken warfarin for 35+ years (artificial Aorta valve) the care that hospice plans may be different from the goals that a physician plans in daily living. The nurse may have in mind that the patient switch back to warfarin. For all of its faults, it can be better controlled in a medical crisis and tested frequently. Warfarin can be blocked quickly if an operation is needed. Eliquis is fine in a regular daily setting and no regular testing ; but I don't think it can be quickly counteracted if needed and switched to Heparin in a short time. Also there is a cost factor involved that at one time was significant. Bottom line only the patient's doctor should be making that decision anyway.
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Often, many of the prescribed hospice meds will have side effects leading to death of our LO. Hospice is aware of this. While the medication may fix one issue, it can give you a whole new bag of issues. Hospice is only about providing comfort in the last season of a person’s life. They definitely don’t want to prolong it. And that’s why they are ok with side effects from medications or taking our LO off medications that will only lead to more medical issues or even death.
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I've had recent experience with my stepdad and FIL both enrolled in hospice care. Both had all of their medication discontinued. Hospice to me is a realization that no one is prolonging their lives by giving them any meds, only comfort care meds. My fil had his Eliquis and more stopped and my stepdad had a bunch of heart meds stopped. Neither one wanted to continue their former medications, they didn't want to prolong their suffering.

My father-in-law had congestive heart failure and dementia and he became very weak and within days was in a coma like state. During the span of one week, he was able to walk on his own, to using a walker, to being bedbound. He had pretty startling shortness of breath too. His passing was very quick. We thought he'd have more time but knowing him, he'd be happy to have passed much sooner than weeks to months. He died one week from being released from the hospital due to a late night ER visit for shortness of breath.
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I JUST went through this. Hospice canceled all of my grandfathers meds on Good Friday. They told me he had maybe a week and it truly seemed like that at the time. Now since time has passed he is doing better, not great, but not one foot in the grave. I called hospice and asked about putting him back on a blood thinner because of his prior stroke and they agreed. If he starts falling or having bleeds I’ll take him off. Blood thinners are good and they are awful. It’s also very hard to adjust to having you LO on hospice.
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There are "formulary" medications that Hospice will cover and pay for.
Other medications can be prescribed but may be "out of pocket" expense.
You can discuss with the Hospice Nurse and the Hospice Doctor about keeping her on the medication they have been known to cover meds that are out of the norm.
It never hurts to ask and go above the Nurse and ask to talk to the Case Manager and or the Doctor.

Because she is at home you can request full bed rails (unless you think your mom would try to get over them) that would keep her in bed.
You could see if Hospice would provide a floor or bed alarm that would alert you if she got up.
If she falls only because she does not have her walker and not because it is difficult to see there is not much you can do other than try the rails or the alarm.
If she falls because she can not see well in the dark try motion sensor lights in the halls and in her room. There are adaptors that you can put in a light socket then the bulb and it becomes a motion sensor activated light.
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A side comment from reading your post. It sounds as though you are caring for your mother at home, with some help from your elderly father. You can get a pressure mat to put beside your mother’s bed, which will alert you to when she gets out of bed. That might be an improvement on her going on to fall, and then having to be picked up off the floor. You may be strong enough to do it, but a slip could damage her, your father and yourself. Reducing the falls may also be relevant to the need for blood thinners, and their risks.
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They may allow her to keep taking Eliquis, but because of its elevated cost, you will have to buy it out of your own pocket. The benefits if any from Eliquis, is that she won't die from a thrombotic stroke. However, might die sooner from heart failure, a fall, internal bleeding or a hemorrhagic stroke.
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I refused blood thinners as an RN when diagnosed with chronic atrial fib two decades ago. SO has it also for about that amount of time; we both take a daily baby aspirin. As an RN I never saw so many complications from ANYTHING as I did from blood thinners. While they can prevent clot stroke (the more common) they are deadly for hemorrhagic strokes and they often cause patients to simply bleed out from one place or another. My vote goes to the decision to stop it. However, if she SHOULD have a stroke you may blame that.
General hospice means "no treatment" for anything save conditions that need comfort care. You can speak with them and they will likely allow you to keep elequis on board. Often blood thinners have a need for monitoring by blood test. They won't want to move Mom to lab or hospital for that, so it all depends if it can be monitored in home/in facility, likely.
You now have Mom in Hospice. They will be VERY OPEN to your discussing all of this with you. Do speak with them. I am wishing you luck, and you are so correct that it is a trip to move from watching for and treating everything to accepting that end of life approaches and treating only those things that give a better quality of life.
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Melanie62 May 2022
Warfarin is only used in certain situations. You do not need bloodwork monitored with other newer blood thinners they have been using past several years.
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Due to excessive nose bleeds, and I mean HORRIBLE nose bleeds that brought her to the ER numerous times, my mother had to be taken off blood thinners several years before she died. She had afib and congestive heart failure too, and dx'ing blood thinners did nothing to 'hasten' her death! The Xarelto, in fact, worsened the quality of her life significantly.

The quality of your mother's life now sounds terrible, frankly, and not something I would want to prolong if I were in your position. Dx'ing the Eliquis is not likely to 'hasten' her demise, as it didn't for my mother. Your mother will pass when it's her time to go. The goal of hospice is to minimize her regular medications in order to allow nature to take its course, using whatever medications (like Ativan and morphine) are required to keep her comfortable and not agitated. Those meds won't kill her or hasten her demise, either, just keep her comfy during her end of life process. But, it's up to YOU what meds you'd like discontinued; hospice will always consult you before doing anything, including administering comfort meds. If you feel it's better to keep her on the Eliquis, then do so. Also, make sure it's hospice's plan TO consult you about the meds, so you'll have a say in her care.

Hospice will let you know when they feel the end is near in terms of end of life signs your mother will exhibit. When my mother with advanced dementia was nearing the end of her life and on hospice, she took to her bed one day. Her heart was giving out and her body was exhausted. She went to bed on a Tuesday and became semi-comatose; she passed away the following Tuesday evening. Hospice was wonderful in keeping her comfortable and out of pain and agitation using a minimum of medications. By the time she had taken to her bed, my mother had fallen 95x! While she didn't hurt herself badly, it was a miracle due to the blood thinners she'd been on!!! That's a big factor for your mother too! Taking her off of the Eliquis, in my opinion, will be a blessing for the falling factor alone.

Before she took to her bed, her large appetite diminished quite a bit and she was picking at her food. She was short of breath all the time, but refused to wear oxygen full time. She was falling more often, too. And her confusion and agitation levels were rising continuously; she had to take higher doses of Ativan to stay on an even keel toward the end. She forgot how to use the phone and no longer was able to call me. She lost her core strength and was slumped over in her wheelchair, and leaning far over to the right (leading me to think she'd had a stroke, but no diagnostics are done with hospice, so we'll never know for sure). Those were the end of life signs she was exhibiting for at least 6 months prior to her death.

Your mother is end stage and terminal, as her PCP has told you, and as evidenced by hospice accepting her into their services. There's nothing more to do for her, medically speaking, but to keep her comfortable. That was my desire for my mother, b/c with dementia and CHF, afib and pulmonary hypertension going on, the last thing on earth I wanted to do was to extend her life at all. She was ready to transition, too, and wound up passing quickly and painlessly under hospice care. For that I am eternally grateful. She was 95 and lived a good, long life. Dementia and all those heart conditions were only making her final days miserable.

Wishing you the best of luck with all you have on your plate.
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notgoodenough May 2022
Ugh, how could I have forgotten about the nose bleeds...when my mom got them it looked like someone was martyring a saint with the amount of blood..
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Frankly, I think blood thinners are overprescribed as an insurance policy against what-ifs.

Unfortunately, your mom's history of falling while being on blood thinners makes her a prime candidate for a brain bleed if she hits her head. That happened to my FIL, and he went from a generally healthy guy with only a bad knee and a 10-year-old stent (therefore the blood thinners) to dead in 24 hours when he tripped, fell, and hit his head.

My mother had Covid when she first went on hospice in January of last year. She developed venous ulcers -- huge blood blisters that would burst and leave big open wounds on her legs -- so the hospice folks decided she needed to be off blood thinners to keep the complications to a minimum. They took her off them around mid-February, and she lived until the end of July and never had a stroke or blood clots.

Around two weeks before she died, it became clear that her CHF medications were no longer working. Her heart rate woqld go up and down for no apparent reason, and the same with her blood pressure. I said to the hospice nurse that it seemed like her meds didn't do anything any longer, and she said, "That's something we need to talk about."

We did talk about it, and it was at that point we decided it was time to focus solely on medications that kept her comfortable. We stopped her heart and BP meds, plus her Lasix, and amazingly, everything settled down, PLUS her edema went away. She truly was comfortable at last. The nurse continued to dress the leg wounds daily, and eventually she told me I might want to get my brother to come visit. I never saw anything significantly different in her condition, except she started looking like a completely different person. She was always overweight and had a round face, but her face became very angular and more slack, and in those last weeks she lost most of her hair. She suddenly looked just like her father.

My brother and I stayed with her all day for the next three days, and she died peacefully the morning of the fourth day before I got there. (She was in a memory care facility.)
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This is how I feel about blood thinners. My Dad had been on them for years because of his heart. Then they started causing internal bleeding. Since the cause could not be found, he was taken off hoping the blood would clot and stop the bleeding. I think he was on Hospice at the time. Internal bleeding is a downside to blood thinners.

I would talk to the Nurse and ask why she felt Mom should go off, actually, she can't make that decision, a doctor does. Always a doctor's order has to be in place.
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According to hospice rules, medications to treat the terminal diagnosis should be stopped. Her terminal diagnosis is heart disease (heart failure and A fib). Any medicine related to her heart problems are stopped because they will only prolong the end. She is dying from heart failure and A-fib. No medicines will avoid her death. The best they can do is to prolong her suffering. Therefore, they must be avoided. She is at the point in which death is better than to continue fighting a lost war which is causing suffering with no hopes to gain anything.
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msfaithk906 May 2022
Actually they WILL cover the eliquis. They will not pay for any medications that are intended to CURE her illness though. Eliquis does not cure her it just prevents her from suffering from a stroke which under their guidelines of comfort care a stroke would cause discomfort. So it is up to us to decide if we want to continue or discontinue.
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My mom passed in 2020, age 86 from CHF while under hospice care.

Hospice was a blessing to her and to me. They made her death peaceful and pain free.

They also recommended discontinuation of medication when she first enrolled. But the nurse explained that if mom chose to stay on those meds, it wouldn't disqualify her from hospice services; hospice just wouldn't provide those meds. Mom could still get them through her prescription plan. They also cleared the discontinuance with her cardiologist, who was mom's hospice doctor. It was mom's decision to discontinue what they recommended, and I have to say it didn't make much of a difference in how she felt, nor did it hasten her passing.

But you have legitimate questions about the meds; you should reach out to your hospice nurse and talk to him/her. Tell them honestly about your fears and doubts. Your concerns are not unreasonable. My mom's hospice was very patient with me and all of my questions. Hospice is there for the family nearly as much as for the patient.

Feel free to PM me with any specific questions, and I'll try to answer as best as I can.

(((hugs)))
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Clairesmum May 2022
Hospice nurse here...your information is right on target. The risk of bleeding due to a fall is higher than the risk of a possible stroke. If a stroke occurs, it is part of the process of dying. Can happen in patents with no cardiac or neurological disease.
I cared for a couple of patients who had unwitnessed falls that were not reported right away. One patient had injured her abdomen in some way - and had a painful death from internal bleeding that might have been managed much better if her hospice team had been told about the fall when it happened.
Even for non hospice patients, the risks of blood thinners start to outweigh the benefits at advanced ages.
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Honestly, I would rather risk a stroke then her bleeding from falling everyday.

I think it comes down to quality and what is the least harmful.

You are dealing with a maybe versus a daily occurrence.

I would speak to her cardiologist.
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MJ1929 May 2022
If she's on hospice, she doesn't have a cardiologist any longer. The hospice doctor becomes her doctor.
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