This is for you.

For every family who has ever stood at this threshold and not known what to ask, what to expect, or what comes next.

Waldo Rios

“This is compiled in the name of every family I have served and every patient I have been blessed to know. May what you find here give you strength and courage — carried to you from the many who have walked this road before. We are here. You are not alone.”

— Waldo Rios, NP

Evidence-Based

💛 You just found out. Start here.

When someone you love has a terminal illness, it doesn't come with instructions. This page walks you through the journey step by step — from understanding what hospice is, to caregiving at home, to what happens after. Scroll at your own pace, or use the timeline above to jump ahead.

Every guide below is grounded in the same evidence that clinicians use, written in language that doesn't require a medical degree.

START HERE

Where are you right now?

2
Understanding Hospice
What it is, what it covers, and your rights as a family.
Download Full GuidePDF · 5 pages
Inside this guide
  • What hospice is (and what it is not)
  • The 4 levels of hospice care
  • Your hospice team and their roles
  • What Medicare covers at $0 cost
  • How to qualify and who can refer
  • Your rights as a hospice family
⚖️

Your Rights as a Hospice Family

You have more power than you think. Here's what you can ask for, what's covered, and what to do if things aren't working.

💰

What Medicare Covers

  • Doctor and nurse visits
  • All medications for the terminal illness
  • Medical equipment (hospital bed, wheelchair, oxygen)
  • Medical supplies (bandages, catheters, gloves)
  • Hospice aide and homemaker services
  • Physical, occupational, and speech therapy
  • Social worker services
  • Dietary and spiritual counseling
  • Short-term inpatient care for symptom crises
  • Respite care (up to 5 days so you can rest)
  • 13 months of grief/bereavement support after death

Your cost: $0 for most services. Up to 5% copay for inpatient respite care.

Source: Medicare.gov

🔄

You Can Change Providers

  • You can fire your hospice and transfer to another provider at any time
  • You can request a different nurse, aide, or social worker
  • You can change hospice providers once per benefit period
  • The transfer must happen in a timely manner — they cannot delay it
  • Equipment, medications, and care continue without interruption
  • Even in a nursing home, you choose your hospice — not the facility

To switch: call your current hospice and request a transfer form. Your new hospice will handle the rest.

Source: Compassus

📋

You Can Always Ask For

  • A family meeting — with the full hospice team to discuss the plan of care
  • Continuous care — a nurse at the bedside up to 24 hours during a crisis
  • Respite care — 5 days in a facility so you can sleep, travel, or rest
  • Chaplain or social worker — even if you haven't been assigned one, you can request visits
  • To see the plan of care — it's your right to know the plan and to disagree with it
  • A different medication approach — if something isn't working, say so
  • To leave hospice — you can revoke hospice at any time and return to curative care

You are the decision-maker. The team works for you.

📞

If Something Is Wrong

  • Talk to the hospice patient advocate or administrator first
  • Call 1-800-MEDICARE (1-800-633-4227) to file a complaint
  • Contact your state health department's hospice licensing division
  • Request a copy of the Patient Bill of Rights — every hospice is required to give you one

You deserve quality care. Advocating for your loved one is not being difficult — it's being a good caregiver.

Source: Medicare Hospice Benefits (CMS)

3
Advance Directives
The legal documents that protect your loved one's wishes.
Download Full GuidePDF · 5 pages
Inside this guide
  • What advance directives are
  • Living will explained
  • Healthcare power of attorney
  • POLST / MOLST forms
  • DNR in plain language
  • How to start the conversation
📋

Advance Directives — Planning Ahead

The legal documents that make sure your loved one's wishes are honored — even when they can no longer speak for themselves.

📝

What Are Advance Directives?

  • Living Will — A legal document stating what medical treatments someone does or doesn't want
  • Healthcare Power of Attorney (DPOA) — Names a person to make medical decisions when the patient can't
  • POLST/MOLST — A physician-signed medical order for life-sustaining treatment
  • DNR (Do Not Resuscitate) — A medical order instructing not to perform CPR

These documents work together. Having all of them gives the clearest picture of your loved one's wishes.

When to Have the Conversation

  • Now. The best time is before a crisis — not during one
  • While your loved one can still speak clearly and make decisions
  • Before a hospitalization or surgery, if possible
  • When starting hospice — the social worker can help facilitate this
  • It's never "too early" — and it's rarely too late

This conversation is a gift to your family. It removes the burden of guessing.

How to Get Them Done

  • Ask your hospice social worker — they do this regularly and can guide you
  • Use free state-specific forms from Five Wishes or PREPARE
  • Most states require two witnesses and/or notarization
  • Give copies to: the healthcare proxy, the doctor, the hospital, and the hospice
  • Keep the original somewhere accessible — not in a safe deposit box

You do not need a lawyer for most advance directives.

Source: National Institute on Aging

💬

How to Start the Conversation

  • "I want to make sure we honor what you want — can we talk about it?"
  • "If you couldn't speak for yourself, what would matter most to you?"
  • "What would a good day look like? What would you want to avoid?"
  • "Who do you trust most to make decisions for you?"

It doesn't have to be one big conversation. It can happen over several small ones.

4
Caregiving at Home
Practical day-to-day guidance for caring for your loved one.
Download Full GuidePDF · 6 pages
Inside this guide
  • Setting up the home for comfort
  • Bathing, turning, and skin care
  • Managing eating and hydration changes
  • What to do when symptoms change
  • When to call hospice vs. 911
  • Daily caregiver checklist
📋

Daily Caregiver Checklist

A simple daily tracker to help you remember what happened, what was given, and what to tell the nurse. Print it out and keep it by the bedside.

Download PDF
Date
Patient
😣 Pain & Comfort
Pain level (0–10)AM: ___   PM: ___
Where is the pain?
Restless or agitated?☐ Yes   ☐ No
Comfortable / sleeping peacefully?☐ Yes   ☐ No
💊 Medications Given
MedicationTimeHelped?
__________________☐ Y ☐ N
__________________☐ Y ☐ N
__________________☐ Y ☐ N
__________________☐ Y ☐ N
🥤 Food & Fluids
Ate anything?☐ Yes   ☐ No   ☐ Sips only
Drinking fluids?☐ Yes   ☐ No   ☐ Sips only
Swallowing OK?☐ Yes   ☐ Difficulty   ☐ Unable
📝 Body Functions
Bowel movement?☐ Yes   ☐ No
Urinating?☐ Normal   ☐ Less   ☐ None
Skin changes? (color, sores)☐ Yes   ☐ No
💭 Mood & Awareness
Alert / responsive?☐ Yes   ☐ Some   ☐ No
Confused or seeing things?☐ Yes   ☐ No
Anxious or fearful?☐ Yes   ☐ No
Overall mood
🩺 Nurse Visit & Notes
Nurse visited today?☐ Yes   ☐ No
What the nurse said:
Questions for next visit:

💡 Tip: Print several copies and keep them by the bedside with a pen. When the nurse calls or visits, you'll have everything in one place.

📞

When to Call — Hospice vs. 911

Knowing who to call — and who NOT to call — can prevent unwanted interventions and get your loved one the right help fast.

Download PDF
✅ CALL HOSPICE Your hospice number — available 24/7
  • Uncontrolled pain — medications aren't working, or pain is getting worse
  • New or worsening symptoms — fever, vomiting, bleeding, new confusion
  • Breathing changes — shortness of breath, noisy breathing, long pauses
  • Falls — even if they seem OK, the nurse needs to assess
  • Medication questions — "Can I give another dose?" "It's not working" "I spilled it"
  • Comfort kit is running low — the nurse can arrange refills
  • Equipment problems — hospital bed, oxygen, suction machine
  • You're not sure what's happening — if something feels wrong, call. That's what they're there for.
  • You're overwhelmed — they can send help, arrange respite, or just talk you through it
  • After death occurs — call hospice first. There is no rush. The nurse will come to you.
🚫 DO NOT CALL 911 Unless there is a safety emergency unrelated to the illness
  • When death occurs — paramedics are legally required to attempt resuscitation. Call hospice instead.
  • When they stop eating or drinking — this is expected. The hospice team is managing it.
  • When breathing changes — irregular breathing, pauses, and the "death rattle" are part of the dying process.
  • When they become unresponsive — this is a natural progression. Call your nurse, not 911.
  • When they have a fall (unless you suspect a broken bone you can see) — call hospice for assessment.
  • When they seem confused or agitated — this is terminal restlessness. Your nurse has medications for this.
Why this matters: If you call 911, paramedics must follow emergency protocols — which may include CPR, intubation, and transport to the ER. These interventions can cause suffering and go against your loved one's wishes. Your hospice team is trained for exactly these situations.
⚠️ EXCEPTIONS — When 911 IS Appropriate
  • Fire or gas leak in the home
  • Caregiver medical emergency — if YOU are having a heart attack, stroke, or medical crisis
  • Violence or intruder — a safety threat to anyone in the home
  • Natural disaster — flood, tornado, or structural collapse

These are emergencies where the patient's hospice status is not relevant. In these cases, call 911 AND your hospice team.

Write your hospice number here and put it on the fridge:
Hospice #: ___________________________________
5
Comfort Meds & Pain Management
Understanding the medications and how to keep them comfortable.
Download Full GuidePDF · 6 pages
Inside this guide
  • Understanding pain at end of life
  • Common pain medications explained
  • Morphine myths debunked
  • Non-drug comfort measures
  • How to manage breakthrough pain
  • When and how to give rescue doses
💊

The Comfort Kit — Medications Explained

Your hospice team may leave a small kit of medications at home for fast symptom relief. Here's what each one does, in plain language.

Download PDF
12 medications
Morphine (Roxanol)
Liquid concentrate
What it's for Pain and shortness of breath
How it's given By mouth or under the tongue — works in 15–30 minutes
"Will it hasten death?"
No. When properly dosed, morphine relieves suffering without hastening death. The dose is carefully adjusted by your hospice team. The goal is comfort — not sedation.
Lorazepam (Ativan)
Liquid or dissolving tablet
What it's for Anxiety, restlessness, trouble sleeping, seizure prevention
How it's given By mouth, under the tongue, or as a dissolving tablet
"Will they be too sedated?"
The dose is adjusted to relieve anxiety while keeping your loved one as alert and comfortable as possible. If they seem too drowsy, tell your nurse — the dose can be reduced.
Haloperidol (Haldol)
Liquid
What it's for Confusion, agitation, terminal restlessness, nausea and vomiting
How it's given Swallowed as a liquid — can also be given under the tongue
"They're seeing things — is that bad?"
Hallucinations at end of life are very common and usually not distressing to the patient. Haloperidol is used when the person is visibly agitated or uncomfortable — not just because they're seeing things.
Atropine (eye drops)
Drops given under the tongue
What it's for Excess secretions — the "death rattle" or noisy, gurgling breathing
How it's given 2–3 drops placed under the tongue (they're actually ophthalmic drops repurposed for this)
"That rattling sound is terrible."
The sound is often much more distressing to family than to the patient. Your loved one is usually unaware of it. Atropine helps dry the secretions and reduce the noise. Repositioning can also help.
Acetaminophen (Tylenol)
Suppository or liquid
What it's for Mild pain and fever
How it's given As a rectal suppository (when swallowing is difficult) or liquid by mouth
"Can't they just take a regular Tylenol?"
When swallowing becomes difficult or unreliable, the suppository form ensures the medication still works. Your nurse will guide you on which form to use and when.
Prochlorperazine (Compazine)
Suppository
What it's for Nausea and vomiting
How it's given As a rectal suppository — bypasses the stomach entirely, so it works even when they can't keep anything down
"They can't keep anything down."
That's exactly why this medication is in suppository form. It goes to work without needing to pass through the stomach. Your nurse can show you how to administer it comfortably.
Promethazine (Phenergan)
Suppository or tablet
What it's for Nausea, vomiting, and restlessness — also has a mild calming effect
How it's given As a suppository when swallowing is difficult, or by mouth as a tablet
"How is this different from the other nausea meds?"
Phenergan has a mild sedating effect, which can be helpful when nausea comes with restlessness or when your loved one needs to rest. Your nurse will choose the best anti-nausea medication based on what else is happening.
ABH Gel (Compounded)
Topical gel applied to the wrist
What it's for Nausea, anxiety, and agitation — combines Ativan, Benadryl, and Haldol into one topical gel
How it's given Rubbed on the inside of the wrist — absorbs through the skin, no swallowing needed
"They can't take anything by mouth anymore."
That's exactly when ABH gel is most useful. It's a compounded medication (specially mixed by a pharmacy) that absorbs right through the skin. Just rub a small amount on the inner wrist and rotate sides. Your nurse will show you how.
Hydromorphone (Dilaudid)
Liquid, tablet, or compounded
What it's for Moderate to severe pain and shortness of breath — stronger than morphine by volume
How it's given By mouth, under the tongue, or as a compounded preparation when other routes aren't possible
"Why did they switch from morphine?"
Sometimes morphine isn't tolerated well — it can cause itching, nausea, or isn't effective enough. Hydromorphone works similarly but may be better tolerated. The switch doesn't mean things are worse — it means the team is fine-tuning comfort.
Bisacodyl (Dulcolax)
Suppository
What it's for Constipation — a very common side effect of opioid pain medications like morphine and hydromorphone
How it's given As a rectal suppository — usually works within 15–60 minutes
"They haven't had a bowel movement in days."
Constipation is extremely common with pain medications and reduced food intake. It can cause real discomfort. Dulcolax suppositories provide reliable, gentle relief. Let your nurse know — they'll help manage this proactively.
Ondansetron ODT (Zofran Sublingual)
Dissolving tablet (sublingual)
What it's for Nausea and vomiting — dissolves on or under the tongue without water
How it's given Placed on the tongue where it dissolves in seconds — no swallowing or water needed
"What if they can't swallow the tablet?"
The ODT (orally disintegrating tablet) melts on the tongue almost instantly. It's designed specifically for people who can't swallow pills or keep liquids down. You can also place it under the tongue if the mouth is very dry.
Oxygen (Comfort measure)
Nasal cannula or mask
What it's for Shortness of breath and air hunger — used for comfort, not to extend life
How it's given Through a nasal cannula (small tubes in the nose) or face mask — your hospice team sets the flow rate
"Should we keep the oxygen on all the time?"
In hospice, oxygen is a comfort measure. If your loved one seems comfortable without it, it's OK to remove it — especially if the cannula or mask is irritating them. A fan blowing gently on the face can also relieve the sensation of breathlessness. Talk to your nurse about what's helping most.
Important: Never change a dose or give medication without direction from your hospice nurse. The comfort kit is there so relief is immediate — but always call first. Your nurse is available 24/7.

🤲 Beyond Medications — Comfort Tips

Sometimes the most powerful comfort measures don't come from a bottle.

🧊
Cool rags on the forehead and neck

A cool, damp washcloth on the forehead, neck, or wrists can bring real relief — especially with fever or restlessness. Refresh it often. Simple, immediate, and something you can always do.

🤫
Keep the environment quiet and calm

Lower the lights, turn off the TV, minimize visitors coming and going. A calm room helps reduce agitation and restlessness. Soft music or nature sounds can be soothing — but silence is OK too.

👂
They can still hear you

Hearing is believed to be one of the last senses to go. Even when your loved one can't respond, they may still hear you. Speak gently. Say what you need to say. Your voice is a comfort they recognize.

📱
Put family on speakerphone

If extended family can't be there in person, put them on speakerphone or video call. Let them talk to your loved one. The familiar voice of a grandchild, a sibling, or an old friend can be deeply meaningful — even if there's no visible response.

💧
Mouth care matters

When they stop drinking, the mouth dries out quickly. Use damp mouth swabs, a wet washcloth, or lip balm to keep lips and mouth moist. This is one of the most comforting things you can do.

🌬️
A fan near the face

For shortness of breath, a small fan blowing gently toward the face can reduce the sensation of air hunger. This works even better than you'd expect — studies show it's as effective as low-flow oxygen for some patients.

🤝
Touch and presence

Hold their hand. Gently rub their arm. Sit beside them. You don't need to talk. Physical presence and gentle touch release oxytocin and reduce stress — for both of you.

🔄
Reposition gently

Turning them slightly every few hours prevents pressure sores and can ease breathing. Use pillows to support. Your nurse can show you how to do this safely and comfortably.

Questions to Ask Your Hospice Team

You don't have to figure this out alone. Here are the questions other families wish they'd asked sooner — organized by who to ask.

Your hospice nurse is your frontline resource — they visit regularly and are available 24/7 by phone.
Your hospice social worker helps with the practical, emotional, and financial side of things — don't hesitate to lean on them.
The hospice chaplain is there for spiritual and emotional support — for any faith tradition, or no faith tradition at all.
The hospice physician (or your loved one's doctor working with hospice) oversees the medical plan of care.
Print All Questions Tip: Check the boxes during your visit to track what you've asked.
📖

Glossary of Terms

Hospice has its own language. Here's what the words actually mean — in plain English.

6
Self-Care for the Caregiver
You cannot pour from an empty cup. Resources and support for you.
Download Full GuidePDF · 4 pages
Inside this guide
  • The truth about caregiving
  • Recognizing burnout — signs to watch for
  • Respite care: your right to rest
  • Asking for help: real scripts you can use
  • Understanding anticipatory grief
  • Your physical health matters too
💚

Caregiver Support & Resources

Caregiving is one of the hardest things a person can do. You cannot pour from an empty cup. These resources are here for you.

🆘

If You're in Crisis

988 Suicide & Crisis Lifeline Call or text 988
Crisis Text Line Text HOME to 741741

Caregiver burnout is real. You matter too.

🛌

Respite & Caregiver Relief

Hospice respite care — Up to 5 days in a facility so you can rest. Medicare-covered. Ask your social worker.
ARCH National Respite Network — Find local respite providers. (703) 256-2084
Caregiver Action Network — Free support, education, and resources. (855) 227-3640
Hospice volunteers — Every hospice has a volunteer program. They can sit with your loved one while you take a break.
🤝

Practical Help

CaringBridge — Free personal health journals to keep family updated without repeating the story.
Lotsa Helping Hands — Organize meal trains, rides, and help from your community.
Eldercare Locator — Connect to local aging services. (800) 677-1116
NHPCO HelpLine — Hospice information and referral. (800) 658-8898
7
The Dying Process
What to expect as end of life approaches — a timeline and guide.

The body does not stop eating because it is starving. It stops eating because it is done. There is a difference.

Waldo, NP
Download Full GuidePDF · 5 pages
Inside this guide
  • Weeks before: sleep, appetite, withdrawal
  • Days before: body changes to expect
  • Hours before: breathing, color, awareness
  • What is "normal" vs. what needs a call
  • How to provide comfort at each stage
  • The moment of death — what it looks like
🕐

What's Happening — A Timeline

The physical and emotional changes you may see as your loved one approaches the end of life. Every person is different — this is a general guide, not a script.

Download PDF
📊

The Journey — At a Glance

A visual overview of what to expect as the body begins to slow down. Every person is different — this is a general guide, not a rulebook.

Months Before
1 – 3 months
Sleeping more Eating less Withdrawing socially Less interest in news & activities
They are beginning to let go. This is normal.
Weeks Before
1 – 2 weeks
Sleeping most of the day Confusion or disorientation Talking to deceased loved ones Picking at clothes or sheets Restlessness
Their body and mind are preparing. Your presence is the comfort.
Days Before
1 – 3 days
Mottled skin (purple/blue patches) Cool hands & feet Not eating or drinking Breathing pattern changes Longer periods of sleep
The body is shutting down gently. Keep lips moist. Speak softly — hearing is the last sense to go.
Final Hours
Hours
Irregular breathing or pauses Gurgling sound (death rattle) Eyes open but unseeing Jaw relaxed, mouth open Possible surge of energy
You can hold their hand, play their favorite music, or simply be there. You are doing enough.

"Is This Normal?"

Things that look alarming but are actually a normal part of the dying process. Knowing what to expect can save you from panic.

8
After Death
What happens in the first hours and days — and what you need to do.
Download Full GuidePDF · 4 pages
Inside this guide
  • The first moments — what to do (and not do)
  • Who to call and in what order
  • What happens with the body
  • Practical steps in the first 48 hours
  • The death certificate process
  • Bereavement support available to you
🕊️

After Death — The First 48 Hours

When the moment comes, there is no rush. Here is a step-by-step guide for what happens next — and what you do NOT need to do right away.

Download PDF
1
Right Now The first minutes
There is no rush. Take as long as you need. Sit with them. Hold their hand. Pray. Be still. Nothing needs to happen immediately.
Call your hospice number. Tell them your loved one has died. A nurse will come to the home to pronounce death and handle the medical details.
⚠️Do NOT call 911. Paramedics are legally required to attempt resuscitation. The hospice nurse handles everything.
Call close family members who want to be there. Everyone else can wait.
You can bathe and dress them if you wish. Some families find this meaningful. It is not required — the funeral home can do it.
2
First Few Hours After the nurse visits
The hospice nurse will: pronounce the time of death, call the physician, complete paperwork, dispose of remaining medications, and contact the funeral home you've chosen.
If you haven't chosen a funeral home, the nurse or social worker can help you find one. You do not need to have this decided in advance.
The funeral home will come to transport the body. You can take as long as you need before this happens. Tell them when you are ready.
Hospice equipment (hospital bed, oxygen, etc.) will be picked up. The hospice team arranges this — you don't need to call anyone.
3
First 24 Hours Things that can wait until tomorrow
Notify other family and friends. Ask one person to be the point of contact so you don't have to make 50 calls.
Gather important documents: birth certificate, Social Security card, marriage certificate, military discharge papers (DD-214), life insurance policies, will/trust.
Contact the funeral home to discuss arrangements (burial vs. cremation, visitation, service). They will guide you through every step.
Secure the home. Lock doors, turn off medical equipment, secure valuables and medications. Return unused comfort kit medications to hospice or pharmacy.
4
First Week Take these one at a time
Order death certificates — request at least 10 copies. You'll need them for insurance, banks, property, and government agencies.
Notify Social Security — call 1-800-772-1213. The funeral home may do this for you.
Contact life insurance companies with a death certificate copy.
Notify employer, pension, and VA (if applicable).
Hospice bereavement services will contact you. Medicare covers 13 months of grief support — phone calls, visits, support groups. Accept the help.
Accept help from people. When they say "let me know if you need anything," say yes. Meals, errands, childcare — let people help.
Remember: There is no wrong way to grieve. There is no timeline. You do not have to do everything on this list today, tomorrow, or even this week. These are suggestions, not rules. The most important thing right now is you.
💜

Grief & Bereavement Support

GriefShare — Faith-based grief recovery groups in your area. 13-week program.
The Compassionate Friends — Peer support after the death of a child. (877) 969-0010
Dougy Center — Grief support for children, teens, and their families. (866) 775-5683
Your hospice bereavement team — Medicare covers 13 months of free grief support after death. Accept the calls.

Find a Funeral Home Near You

If you haven't chosen a funeral home yet, you can search here. Each listing includes a "Questions to Ask" checklist based on your rights under the FTC Funeral Rule.

Waldo Rios

Waldo's Tips

Clinical wisdom and practical advice from 15 years at the bedside.

Waldo, NP

Waldo Rios

Have a question? Ask Waldo.

Caregiving, hospice, medications, "is this normal?" — no question is too small.

I read every question personally. Whether it's something medical, something emotional, or just "is this normal?" — ask.

Your question may be answered in a future Waldo's Tips update (anonymously, with your permission). Your information is never shared or sold.

You are not alone in this.
Every guide on this page is free to download, print, and share. If you are currently on hospice, your social worker and chaplain are available to walk through any of this with you. If you haven't started hospice yet and have questions, call your doctor or reach the NHPCO HelpLine at 1-800-658-8898.