I’ve run up against these kinds of time limits before in my work as an oncology nurse. There’s a certain logic to it: hospice insurance benefits are ideally used to cover the costs of end-of-life care in patients’ homes, for up to six months, while periods of inpatient care are for the “short term.” And although patients do die in inpatient hospices, part of the mission of hospice is allowing patients to remain at home instead of in a hospital; hence the turn away from inpatient care, which is costly and often intrusive.

But that leaves people like this patient — more than a few days away from death, unable to be adequately cared for at home and unable to afford to pay out-of-pocket for a facility — struggling to find a place to die.

Dying at home was neither safe nor compassionate for this patient. She needed constant supervision: she would struggle to sit up and moan in frustration, or lurch dangerously over the side of the bed. Her speech was more sounds than words, and she had no control over her bowels or bladder.

Her husband looked as if he might fold in on himself at any minute, and he’d already borne the burden of care for a long time. Though I didn’t know for sure, it’s likely that his insurance couldn’t guarantee continuous nursing care in the home as a covered expense. And the patient’s children had already lost so much of their mother; she no longer even recognized them. Did they need to witness her final deterioration up close at home?

Home was not the only option. She could have stayed in the hospital and pursued aggressive care. Indeed, if her physician or a family member had said “do everything,” meaning keep her alive as long as possible through intravenous medications and hydration and, ultimately, sending her to the intensive care unit on a ventilator, it would have cost thousands of dollars but, paradoxically, most insurance companies would have considered it a legitimate care option.