When families are unprepared for the natural and often inevitable changes that occur as their loved one approaches the end of life, their reactions can range from decision-making remorse and last-minute panic to outwardly directed blame, both potentially resulting in a liability claim.

Actual Scenarios:

• The adult children kept delaying the Hospice decision. When the resident's terminal status became undeniable, the daughter agreed to Hospice. Within days, the resident expired, and the daughter revealed her belief that going on Hospice should have guaranteed her mother a peaceful 6-month journey toward death. Her distress regarding the resident's very brief time on Hospice lead to a liability claim.
• The son/POA had made care decisions consistent with Hospice status for almost a year. A small area of skin breakdown, which had been stable for at least six months, deteriorated rapidly in the last week prior to the resident's death. When the resident's death became observably imminent, the son insisted upon aggressive attention to the skin breakdown, which he, only weeks before, had declined. The son has since pursued a liability claim with a $1-million demand.
• The resident was on Hospice with predictably poor food/fluid intake. The resident's wife had been very upset about the resident's poor appetite and believed that staff weren't taking enough time encouraging him to eat/drink. When the resident briefly appeared to rally, coincidental to a day when he consumed the ice cream she had fed him, the wife became convinced that he could make a recovery. The facility has received a request for medical records from a plaintiff's attorney.
• A resident in the final days of life begins to show signs of rapid physical decline, including unexpected skin breakdown. Despite the team's attentive care and documentation, the family expresses concern and files a claim, believing the outcome could have been prevented.

Discussion:

Proactive communication and education are key. Families may not be aware of what to expect during the final stages of life. When we take time to explain the physical changes that may occur, we help set realistic expectations, assist families to distinguish between signs of predictable decline vs assuming problems with care, and reduce the likelihood of misunderstandings or claims. The most misunderstood end-of-life phenomena include:

• Rapid onset of skin breakdown/rapid decline of existing areas of breakdown: The general public associates skin breakdown with poor care, so we can expect that families during this emotionally charged period may also make that assumption. The fact that improvement/healing is unlikely is also challenging for families to accept.
• Significantly reduced food/fluid intake: Families often believe that decreased appetite is really a reflection of the staff not trying hard enough to get their resident to eat/drink. Families also may not understand that, at life's end, reduced intake does not result in 'suffering,'
• While we, as providers, are familiar with the brief appearance of 'rallying,' this can often give families a glimmer of hope, however unrealistic, that the resident's passing may not be that imminent.
• Being placed on Hospice status is not a guarantee of a 6-month-long journey.

 Risk Management Strategies:

• Early Conversations: Begin end-of-life discussions well before a resident enters the final days. Use clear, compassionate language to explain what may happen.
• Documentation: Record all communications with families, including education provided about the dying process and care plans in place.
• Team Coordination: Ensure all staff are aligned in messaging and care approaches, especially during Hospice or palliative transitions.
• Visual Aids: Consider using diagrams or handouts to help families understand the physical changes that may occur.

By preparing families with knowledge and empathy, we not only support them emotionally but also protect our teams and communities from avoidable risk.

Contact us today with any questions!