I work for a large nation-wide hospice. Even if a patient is a full code, the hospice does not refuse to admit the pt because we can still help with symptoms, and of course, hospices do want to make money, too. We don't turn away full code pts, however, from the beginning we gradually have the "isn't it time to make him/her a DNR" discussion with the family. It can take days, weeks, or months to convince them that extraordinary measures will likely prolong the patient's suffering, and the result will be the same---death, but probably a painful death. Some families keep the patient a DNR in place until we arrive for the death visit, and once we say the patient has died, they usually give up and decide against CPR--thank goodness. Once a patient of mine died on the toilet (was a full coder). Her family was hysterical and wanted her revived, but i gently took them aside, firmly clasped their hands, and said, "she is gone, be brave enough to not put her through any more indignities." Of course, they cried and guilt permeated the room. Then i called the chaplain. The patient was put back to bed, cleaned up, and by the time the mortuary attendants arrived the family was coping better.
We are not required to take CPR to work at this particular hospice (though i have ACLS); and we are told to not initiate CPR. From the beginning, we tell families that our staff will NOT perform CPR on the pt-- that they have to call 911 for that; and that, if they are taken to the ER, hospice will not foot the bill or pay for any treatment unless it's related to the hospice diagnosis. And they will be revoked from the hospice during their hospital stay. Often they come right back to hospice, and, thankfully, with a DNR in place. It all sounds very cold but they signed up for hospice and it's about letting the patient leave with dignity and respect. In the hospitals, it would behoove the staff to have the hospice discussion long before the patient goes home so the family is prepared.