https://www.facebook.com/222344836430561/

WVMC Palliative and Hospice Care Program, Western Visayas Medical Center, Q. Abeto Street, Mandurriao (2026)

27/04/2026

What Is a DNR and Why Is It Important in Hospice Care?

A Do Not Resuscitate (DNR) order is a medical directive that tells healthcare providers not to perform CPR if a patient’s heart stops beating or they stop breathing. This includes chest compressions, electric shocks, and advanced life support measures.

In hospice care, a DNR is not about withholding care; it is about honoring the patient’s wishes and focusing on comfort, dignity, and quality of life.

For patients with serious or terminal illness, CPR is often unlikely to restore meaningful recovery and may cause additional harm, such as broken ribs, prolonged suffering, or hospitalization that does not align with the patient’s goals (American Heart Association, 2020; NHPCO, 2023).

A DNR allows the care team to fully focus on what hospice does best: managing symptoms, relieving pain, and supporting both the patient and the family through the natural process of dying.

Without a DNR, emergency responders are typically required to attempt resuscitation even if it goes against what the patient would have wanted. This can lead to distress for families and care that does not reflect the patient’s values. With a DNR in place, there is clarity. There is alignment. There is peace.

In hospice, choosing a DNR is not about giving up; it is about choosing how you want to be cared for at the end of life.

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26/04/2026

Hello everyone...
This is the last tip from the “7 days of end-of-life tips.”

I hope they have been helpful, and brought you some comfort or clarity. I appreciate all the comments and personal stories shared, I read every single one!!

Sending you all so much love,
Gabby
❤

End-of-Life Tip #7
“What has death taught me?”

The first death I witnessed was when I was about eight years old. I blocked it out of my memory until I started working as a hospice nurse and wrote my second book, “The Hospice Heart,” where I share childhood stories that indicate I have been preparing to do this work my whole life.

You can find the story of "My First Death" here:
https://www.thehospiceheart.net/post/my-first-death

I have witnessed a lot of death, I have been present for more “goodbyes” than I can even count, and I have comforted thousands of people who were about to begin their grief journey. I have learned many lessons about life, through death.

Doing this work has me questioning my own mortality often. It makes me more aware of the boxes I want checked off before I go. It has opened my eyes so wide sometimes it burns, to how truly fragile life is, and how so many of us take it all for granted. I have used the phrase, “if I only knew then, what I know now,” a billion times. As a hospice nurse, an end-of-life doula, and a death and dying educator I am waist-high in the river of death and dying and yet, the more I swim here, the less I feel fear, and that comforts me. My hope is that I can help remove the fear for you as well.

I have so many take-aways from this work, and so many lessons that have helped me to become the kind of person I’ve always wanted to be, which is someone the people I love would be proud of. Maybe that is my biggest lesson, to live a life where I am my most authentic self, and that I leave a legacy behind that my children and their children would be proud to share.

When someone is dying, many people, myself included, sit at the bedside realizing how much time has been wasted. That last breath takes away future conversations, experiences, and memory making, so what I am reminded of, is how important it is to do that now while we can.

I have learned that we can’t go backwards, we can’t call a do-over, we can’t take back hurtful or unsaid words, or change situations where we could have done things differently. BUT!!! Death also reminds me that we can do things differently moving forward. It reminds me how truly blessed I am to be alive, to have family and friendships, to do work I am honored to do, to stare at the sky with child-like excitement, to dance like a teenager when my favorite song comes on, and to appreciate every single thing that I have in my life right now, and to no longer waste a moment of it or take anything for granted.

From this moment forward, make a difference in this world; for yourself, and for the people who are in your life. They matter. YOU matter. Life matters. Let’s be kinder to one another, more aware of the struggle’s others might be having, and extend a hand, or a hug. Let’s be the kind of people that the people who love us would be proud of. Nothing is guaranteed, all we can be certain of is right this moment… make it magically delicious!

What has death taught me? That time is a gift that cannot be bought, and we shouldn’t waste a minute of it. It has taught me to savor life.

xo
Gabby
www.thehospiceheart.net

For all of my tips, you can find my book “End of Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5

25/04/2026

The Impact of Delayed Hospice Referral on Patient Outcomes and Quality of End-of-Life Care

Late referral to hospice care is a common issue, and it can significantly impact both patient comfort and family experience at the end of life. Hospice is designed to provide comprehensive support over time, not just in the final days. When referrals are delayed, patients often miss out on the full benefits hospice can offer.

One of the biggest concerns with late referral is unmanaged symptoms. Patients may experience uncontrolled pain, shortness of breath, anxiety, or agitation that could have been better managed with earlier hospice involvement (National Hospice and Palliative Care Organization [NHPCO], 2023). Hospice teams specialize in proactive symptom control, but they need time to assess, adjust, and optimize care.

Late referral also limits emotional and psychosocial support. Hospice provides counseling, education, and guidance for both patients and families. When hospice is introduced too late, families may feel unprepared, overwhelmed, and unsupported during the dying process (World Health Organization [WHO], 2020).

Another impact is reduced time for care planning. Early hospice allows for meaningful conversations about goals of care, advance directives, and patient wishes. Without this time, decisions are often made in crisis, which can lead to care that does not align with what the patient truly wanted.

In addition, late referrals may result in more aggressive and burdensome interventions near the end of life, including repeated hospitalizations or procedures that do not improve quality of life. Hospice helps prevent unnecessary interventions by focusing on comfort and aligning care with patient goals (NHPCO, 2023).

Perhaps most importantly, late hospice referral can take away valuable time, time for comfort, closure, meaningful conversations, and presence with loved ones.

Hospice is not meant to be a last-minute decision. It is a supportive service designed to walk alongside patients and families, providing comfort, clarity, and dignity throughout the final chapter of life.

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25/04/2026

7 days of end-of-life tips
Day # 6
“Should we talk to the kids about death?”

One day I was visiting a patient, an 86-year-old father and grandfather. His daughter, a mother of four kids ages 6, 8, 9, and 13, asked me if she should tell the kids he was dying. They knew he was sick, he had been in bed for several weeks, but only recently was sleeping more and became less communicative. The kids had a close relationship with him and saw him every day. I am not a therapist, psychiatrist, or a social worker and I do not pretend to be, I leave the difficult, in-depth conversations for them because they are trained to handle them far more delicately than I, however I did feel it necessary to address it right there and then because I knew he was close.

I asked her how old she was when she first experienced a death. She told me that when she was about 8, the same age as one of her kids, her grandmother died. The way she found out was when family came over, very dressed up, and left her with a sitter. She asked where they were going and one of her aunts told her that they were attending the funeral. She did not get to say goodbye, she did not get to spend time with her, and she didn’t get to go to the funeral, and it has bothered her for years. So, we talked about that, and what it felt like to not be told the truth or given the chance to say goodbye.

Not all children have the emotional maturity to handle and understand death, so I would not immediately tell you to talk to the kids. I would want my granddaughters there with me in my last days. I would want to say goodbye to them, tell them how much I love them, and leave them with sage advice from a life well-lived. I would want them to have the chance to say goodbye, but to also be given the choice whether this is something they would want to do. And if not, I would respect that.

If we are not honest with kids about death and dying, it could affect the way they view death as adults. Kids are less jaded than we are, less affected by years’ worth of traumatic life experiences, and are more likely to see it for exactly what it is; someone they love is not well and they are dying. And if we give them a chance to say goodbye, perhaps draw them pictures, or call them, or send them letters, maybe they will feel a sense of closure in their heart and not carry that with them for the rest of their life. Of course, this would be an entirely different scenario if it was an unexpected sudden death, that would need to be handled more carefully by someone professionally trained to have those conversations.

The daughter asked if I could tell the kids what was happening, which I agreed to do. I explained that his body was tired, and he had been fighting an illness for a very long time but was not strong enough to fight anymore and he was dying. I explained that he probably couldn’t talk to them anymore, but he would know they were there if they wanted to say goodbye. I was asked four questions:

“Is he in any pain?
“Will he hear me?
“Can I hold his hand, is it okay to touch him?
“How soon is he going to die?”

These questions alone should tell you how kids between the ages of 6-13 might be thinking. I answered their questions, and I suggested things they could do for him. The 13-year-old chose not to be present but had his mother bring in a drawing he did of clouds and sky, letting him know he would be in heaven, two of them drew pictures and stayed at his bedside most of the time, and the 8-year-old stayed and sat with us until he took his last breath six hours after our conversation. They were prepared for his death, they were given a choice, and they each got to say goodbye in their own way.

I think it is important to be honest with kids when someone is not well and could be dying. The amount of information should be determined based on their emotional maturity. If they are close to them, if this person has been an active presence in their life, then at the very least they should be told and given the chance to say goodbye if they choose too, and yes, even attend their funeral.

I truly believe that if we talked about death and dying more openly, and normalized the conversation, perhaps there would be less fear and uncertainty, and our children would grow into adults that continue the honest conversations with their own children. What a difference this could make for everyone in how we communicate about and navigate death and dying.

Yes, I think we should talk to kids about death. ♥️

xo
Gabby
www.thehospiceheart.net

You can find my book “End-of-Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5

23/04/2026

7 days of end-of-life tips
Tip # 5
“Why are routine medications discontinued, and food/water stopped when someone is on hospice?”

I have heard from several family members who feel as though starting hospice is what ended the life of the person they love, because they died shortly after admission. There are many misconceptions, most of which could have been avoided if better education was provided.

“When my mom started hospice, they immediately discontinued her medications, and she died.” People honestly believe that hospice is the cause of death, something I want to try to change. Forgive the length of this, but I wanted to be sure to provide as much information to truly honor the fear and hopefully reduce it.

When someone is admitted on to hospice, their medications are reviewed by the admission nurse who collaborates with the hospice doctor to determine which ones are no longer beneficial. There is no need for someone to take 5-10 pills if they are not helping in some way, especially if swallowing has become difficult. They might also be discontinued because they are causing symptoms that can be avoided.

Hospice covers most medications which relate to the diagnosis and the symptoms from the diagnosis. If their current medication is not on the hospice formulary, it would need to be paid for out of pocket. The doctor might suggest a different brand that would be on the formulary, to save the family money.

Medications are discontinued because they are no longer providing a benefit, they are difficult to swallow, or they are expensive and not covered under hospice. The doctor discontinues the medication truly for the safety of the patient. If there is a medication the patient or family wants to continue, the doctor might attempt to have it covered, but if it is not and the family still wants it taken, this can be discussed and might be considered.

Another fear about hospice is that food and water is "stopped" and the patient dies from starvation or dehydration. This is one of the things I hear most often. Food and water is not "stopped," we offer an explanation that it is no longer safe, but it doesn’t necessarily happen at admission UNLESS the patient is declining quickly or actively dying. If someone is struggling with swallowing, their safety is of the utmost importance to the hospice team. We would never intentionally do something that would cause or increase suffering. Usually, we try to help the family understand why the patient is choosing not to eat or drink anymore, while explaining how unsafe it can be for them.

There are a few things I look for to determine if someone has difficulty swallowing:

· They might pocket food in their cheeks.
· They might close their mouth refusing food.
· They might shake their head “no” or turn their head away from the food.
· They might cough when drinking liquids.

If any of these are happening, we know they are trying to let us know that they are no longer interested in eating/drinking and that swallowing is difficult and sometimes even scary for them. Most people think that food and water will help keep their person alive longer, perhaps even stronger, but what they don’t realize is that at a certain point the food and water can become more dangerous and could increase their suffering by causing them to choke. Please know that the body does not need food or water when it is trying to let go. In some ways, the food and water can make it harder to shut down, so discontinuing it can make things more comfortable for them. If your hospice team suggests not forcing food and water, it truly is in the best interest of your person.

If they are still able to eat and enjoy food safely, we are not going to suggest you keep that from them. We are not in the business of starving people; we are always putting their safety first and want to be sure that you do not have to witness further discomfort and suffering. What we will also do is educate you on ways to ensure safe eating and drinking, such as making sure they are sitting upright, and offering smaller and easier-to-eat portions.

Education is key and your questions are valid, appropriate, and absolutely should be addressed. As a hospice nurse, I never want to leave someone feeling fearful or uncertain, and I do not want them thinking that hospice ended the life of the person they love.

I truly hope that this information is helpful.

xo
Gabby
www.thehospiceheart.net

For all of my tips, you can find my book “End of Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5

22/04/2026

7 days of end-of-life tips
Tip #4
Can they hear you? Yes!

When my parents died, a few years a part, I was present for both, but only physically. I didn’t know what to say or do and no one was there to guide me. 30+ years later I am a hospice nurse/end-of-life doula and what I do best is prepare people to be at the bedside of someone who is dying.

I always encourage people to say “the things” because I believe if they are said, maybe they will carry less regret on their grief journey.

If I knew then what I know now, I would have sat at their bedside and at the very least, said goodbye. I have spent all these years wishing I had said so many things.

The first advice I want to give you, is to not wait for the bedside to “say the things." Say them now, when you have a chance. Imagine if you didn’t have years’ worth of held-onto feelings in those last moments, and you could instead simply use that time to say I love you, thank you, and goodbye.

The question that I am asked quite often, is “can they hear me?” I have heard that the hearing ability is heightened at the end of life, but I don’t think that is why they hear us. I think it is our love for one another, our history, our life experiences, our spiritual connection, and the magic and wonder that happens at the end of life when two people have to say goodbye. They hear us because they feel us and they know we are there, and somehow everything we think, feel, and say is handed over to them. I think they need to hear those last words as much as we need to say them, so that is enough for me to be absolutely certain that whatever is said moments before last breaths are taken, are without a doubt heard. Trust that.

While I wish everyone said “the things” way before they find themselves about to say goodbye, I will always encourage people to say whatever they need to before last breaths are taken. I imagine their words as a take-away, a beautifully wrapped gift for the person who is dying to take with them when they go. Sometimes there is history that is not pleasant, perhaps years of disconnect prior to this bedside moment, which means there are years of unsaid words that there will never be enough time for. But what if you apologized, forgave, or made amends and the comfort that might bring. And if the damage and pain is too deep, what if you simply wished them peace, and said goodbye. This is not a moment to make up for lost time, it is a moment to let go and say goodbye, for you and for them.

I believe that people who are dying need to know a few things; that the people they love will be cared for well, that their name will always be said, and that their legacy will be carried on for many lifetimes. And they need to know without any doubt, that they were loved. Imagine if we just said those things.

When you ask me if they can hear you (us), especially when they are non-verbal and cannot respond, my answer will always be yes. You may not get a smile, or opened eyes, you may not hear words in response to yours, or feel a tightly squeezed hand… but I can assure you that whatever you say will be received and it will be the last gift you give them.

But how can I be sure? Because when I was at my brother’s bedside for the 18 days he was in the ICU, I apologized over and over for wasting so much time holding onto anger from a fight we had many years before. The day before he died he woke up. They took him off the ventilator and off oxygen and he was awake. I asked him if he knew I was there and he said, “I’m sorry too.” He heard me.
That’s how I know for sure that the words that you say will be heard.

So, if you find yourself at the bedside of someone who is dying and you love them, let them know, and tell them their life mattered, wish them a safe journey, and say goodbye, because they deserve that. They hear you. I believe this with every ounce of my being.

xo
Gabby

For all of my tips, you can find my book “End of Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5

21/04/2026

7 days of end-of-life tips
Tip #3
Visions, Voices, and Visitors

Pretend for a moment that anything is possible, and our role is not to prove someone wrong, but to instead support them if it brings them comfort. Let’s place scientific proof, endless data, and opinions of others aside for now. These are just my opinions, what I have witnessed, and how I feel about this topic personally.

I visited a man a few weeks before he died. He told me that his dogs, both of which died years ago and years apart, had started to visit him. His question was, “does this mean I am close to death?” I first asked about the dogs, their names, and how it felt to have them there. He was so pleased they were there, and he told me that they didn’t get along well when they were alive and the older one died a few weeks after he got the second, so they didn’t have a lot of time together, but now, as they lay on his bed, they were the best of friends. I explained to him that it is my opinion that when someone is near death, they are more open, perhaps spiritually, maybe intuitively, to welcoming the things we cannot see or hear. I told him that from my experience it doesn’t necessarily determine his timeframe, but that it was my opinion he was close. On the day he died, I was there with him. I asked him if the dogs were there; he patted the bedside (as if to pet them), smiled, and said, “yes.” He died about an hour later.

I have witnessed many people seeing friends or family members that have died, people they didn’t know, one even told me Jerry Garcia played music at her bedside. I have only witnessed one person fearful of what she saw, because it was so startling to her, but soon after, she found comfort in the visits from the stranger. People who can verbalize and are alert and oriented, share their stories with me and I sit almost child-like at their bedside, eager and excited for every word. I see the comfort this brings, but I am also curious and I want to learn more. In many ways it is a hand stretched out, as though someone is saying, “I will take your hand and join you on this next part of your journey so you do not have to do it alone.”

Some people are no longer verbal, but I can tell they either see or hear something by the way they gaze (usually at the wall or ceiling), with glazed eyes, and appear peaceful. Family members worry, they don’t understand, most cannot accept it to be true, so they want to talk them out of what they see or hear and convince them they are wrong, or even medicate them out of their “hallucinations.” I can appreciate the discomfort the unknown can bring, so I always take time to help those at the bedside feel a little more accepting, and hopefully less fearful.

I have learned that some people can have these visions or hear voices months before they die, some it only happens hours or days before, so this cannot be predictable. Most people do not struggle or feel fear, and find comfort, safety, and peace with the presence of the visitor(s). I always encourage families to just listen, and ask questions like, “what do they say?” or “what are they wearing?” If you leave the door open for them to trust you with what they see or hear, they will be more inclined to include you, and trust me, you want to be included.

There is a darker more uncomfortable aspect to this, which some of you might have witnessed. Terminal delirium is a real thing, hallucinations can happen, and fear is difficult to watch. This is that time when it is so important to talk to the doctor and ask what you can do, and most times, medication is key, so my advice is to trust that. Our role as a bedside guide, in any capacity, is to relieve fear, so be sure to honor them by being their fierce advocate.

Whether there is a curtain, a veil, or a sparkly silk cloth that comes between us and whatever is waiting for us on the other side, if someone hears a comforting voice or sees an outstretched hand offering safety on their journey, I believe our role is simply to thank them for being there, and feel comforted that someone you love has a companion to take those next steps with.

Instead of doubting or correcting, ask questions and offer them a safe place to talk about the mysteries and magic of the dying process.

xo
Gabby
www.thehospiceheart.net

For all of my tips, you can find my book “End of Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5/ref=cm_cr_arp_mb_bdcrb_top?

20/04/2026

7 days of end-of-life tips
Tip #2
Medications

I will start by saying that I am not a big fan of medication. And what I mean by that, is that it is not usually my first go-to because I would like to think there are other things we can do first to try and relieve distress, discomfort, and/or suffering, such as repositioning and verbal or tactile stimuli. However, having said that, medication is important to have on hand and will oftentimes be the difference between pain and peaceful.

A comment I hear often is the connection between hospice, morphine, and death. I have heard people say that their loved one died when they were given Morphine. I have not been in your shoes, I wasn’t there when this might have happened, so I can only speak from my own experience and from what I have seen.

The medications commonly used at the end-of-life are Morphine and Lorazepam (Ativan). There are many others, but for now I will start with them. I am not afraid of these medications because I have seen them work effectively and I rely on them. I am not concerned about someone becoming addicted, and while I respect your fear, I encourage you to remove that from the things you are afraid of. If someone is at the end of their life, becoming addicted would be the last thing I want you to worry about.

I find that pairing medications like Morphine and Lorazepam can be very effective, but this too scares people. I take time to explain the “why,” and say “they are good friends, they play nicely together.” What this means to me, is that when given together they can provide more comfort and relief. For instance… if there is pain, it can increase the agitation/anxiety- if there is agitation/anxiety it can increase the pain. If Morphine and Lorazepam are given together they can often simultaneously reduce both (most of the time).

More is not always better. Our bodies react differently to medication, so we cannot assume that what worked for one person will work for another. This also means that we tolerate doses differently as well. For instance, one person can take Lorazepam and feel relaxed and calm shortly after, another person might sleep for an entire day, and someone else might not feel any relief or it will only last 30 minutes. This cannot be predicted.

I have also witnessed pain increase when medication is given, which is why I like to wait to see how a medication works before immediately giving another dose. Each body reacts differently, therefore it is important to determine whether an increase or reduction of medication is needed, or perhaps changing to a different medication.

Constipation is a common side effect when using opioids, but what I also look for is the dry eyes, the dry mouth, and the reddened and warm cheeks because this can be very uncomfortable for someone who is dying. This is where you come in… offer a cold compress on the cheeks and forehead, or wetting eye drops for the eyes (check with the doctor first), and even just one drop of water is comforting to a dry mouth, but please always be mindful of their swallowing ability and that the head of their bed is elevated. If they are alert and oriented, I suggest sugar-free sucking candies or watermelon… both comfort a dry mouth.

Can someone die after taking these medications? Yes. Did you or your doctor or nurse end their life by giving it to them? In my experience I will say no. When someone is suffering and given medication, they might die shortly after. My rationale for this is that the medication allowed them/their body to stop fighting so hard, and give into what was already happening to them, allowing their body to let go. Their diagnosis and disease process ended their life, the medication just gave their body permission to let go with a little more peace and grace.

If you are afraid of the medications being prescribed for someone you love, ask for more information. Not only are you this person's advocate but you will carry this memory with you for the rest of your life and you need to know that you did right by them. And if you are the doctor or nurse suggesting a medication, please offer as much education to the family, allowing them to feel confident with what is being suggested. Education is so important, and can relieve fear.

I think it is very important to respect that medication can be scary, and most people equate it to addiction and death. I alway do my best to remove these fears, making sure they feel confident and comfortable with what is being given, and how their person is being cared for.

xo
Gabby
www.thehospiceheart.net

For all of my tips, you can find my book “End of Life Tips” here:
https://www.amazon.com/Life-Tips-Gabrielle-Elise-Jimenez/dp/B0C9G8PZZ5/ref=cm_cr_arp_mb_bdcrb_top?

WVMC Palliative and Hospice Care Program

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