End-of-Life Care: Questions to Ask When Choosing a Facility

Choosing a long-term care facility or a Continuing Care Retirement Community (CCRC) is a major decision. For those valuing end-of-life empowerment, compassion, and competent care it is essential to know if a facility’s internal policies align with your personal values.

General guides and checklists can help you develop your overall evaluation of assisted living and nursing home facilities. See for example an AARP checklist.

While features such as staffing, accommodations, living space, cost, meal plans and such are important, it is our hope you will also ask about how any facility will consider and honor your long term wishes.

Questions to Consider

1. Will this facility honor my clearly stated end-of-life wishes?

   Ask specifically how they handle Advance Directives, POLST forms, and Do Not Resuscitate (DNR) orders.

• Are these documents honored without hesitation?
• Are they prominently displayed and easily accessible in an emergency?

2. How does the facility respond when a resident declines food or fluids?

   Some facilities have policies that prioritize aggressive feeding when a resident resists eating. In certain situations, a resident may be intentionally reducing intake as part of their end-of-life wishes.

• What is the facility’s policy in these cases?
• Will you honor VSED as a palliative choice, or will it be treated as a medical emergency or “failure to thrive”?
• Are staff trained to distinguish between treatable conditions and a resident’s clearly expressed end-of-life decisions?
• If someone chooses Voluntarily Stopping Eating and Drinking (VSED), would the facility provide appropriate comfort measures and support?

3. What is the approach to palliative care and hospice?

   Palliative care and hospice can significantly improve comfort and quality of life.

• Can I choose any Medicare-certified hospice provider, or am I required to use a “preferred partner” of this facility?
• Are hospice providers welcomed and supported in the building?
• How does staff coordinate care with outside hospice teams?

4. How does the facility handle discussions about medical aid in dying ?

   While MAiD is not currently legal in New Hampshire, policies vary regarding whether facilities allow staff to provide information or assist with transfers to states where it is legal.

• Are conversations about MAiD permitted?
• If a resident wished to relocate to Vermont, where it is legal, would the facility cooperate with that transition?

5. How are spiritual and emotional needs supported?

• Is there a chaplain or spiritual care provider on staff?
• Are residents free to invite their own clergy, end-of-life doula, or spiritual advisors?
• Can I/we speak with the chaplain now to understand how they support residents at end of life?

Questions to Consider

1. Documentation & Legal Rights

• Advance Directives: Will you strictly honor my Advance Directive and appointment of a Durable Power of Attorney for Healthcare (DPOAH)?
• POLST/DNR: How are my POLST (Provider Orders for Life-Sustaining Treatment) and DNR orders communicated to the night-shift and per-diem staff?
• Portability: If I am transferred to a hospital or another wing of this facility, will my original end-of-life documents physically travel with me?

2. Voluntarily Stopping Eating & Drinking (VSED)

• Policy on VSED: What is your facility’s specific policy regarding a resident’s choice to Voluntarily Stop Eating and Drinking (VSED) to hasten the end of life?
• Medical vs. Personal Choice: Will you honor VSED as a palliative choice, or will it be treated as a medical emergency or a psychiatric “failure to thrive” issue?
• Comfort Care: If I choose VSED, will your staff continue to provide attentive comfort care — including mouth care, skin care, repositioning, and symptom management — even as I refuse food and fluids?

3. Hospice & Comfort-Focused Care

• Provider Choice: Can I choose any Medicare-certified hospice provider, or am I required to use a “preferred partner” of this facility?
• Staff Training: Are your nursing and care staff specifically trained in comfort-focused care and the management of “active dying” symptoms?
• Palliative Sedation: Does this facility allow for palliative sedation if pain or respiratory distress becomes uncontrollable at the very end?

4. Medical Aid in Dying (Vermont Option)

• Information Sharing: What is your policy regarding staff or physicians discussing the Vermont Medical Aid in Dying (MAiD) option with residents?
• Medical Records: Will you promptly provide the necessary medical records and certifications to a Vermont physician if I choose to pursue that legal option?
• The “Return” Policy: If I travel to Vermont to pursue MAiD but change my mind or decide the timing is not right, can I ensure that my residency/bed here at this facility guaranteed for my return?

5. Spiritual & Emotional Support

• Inclusivity: Do you provide access to non-denominational spiritual support or end-of-life doulas for those who do not identify with a specific religion?
• Outside Support: May I bring in my own clergy, spiritual advisor, or private end-of-life advocate or doula to support me in my room?

Advocate’s Tip: Don’t be afraid to ask for these policies in writing. A facility’s “philosophy” is important, but their written policy is what governs your care in a crisis. You have the right to choose a home that fully respects your bodily autonomy.