The short version
- In a nursing home, hospice and the facility share the work under a written agreement: hospice manages hospice care; the facility keeps providing room, board, personal care and nursing.
- Federal rules give nursing home residents the right to visitors of their choosing, subject to consent and reasonable clinical and safety limits. A doula comes in as the resident's guest, or under the facility's own role for outside helpers.
- Assisted living and home care are licensed by each state. Check your state's rules and the facility's or agency's own policy.
- A doula never does personal care, never helps with medications, and is not an investigator. Concerns go to staff, and if unresolved, to the Long-Term Care Ombudsman.
- Some facilities run volunteer vigil or doula programs. We name the ones we could document below.
Three rails, kept apart
| Rail | What it looks like in long-term care | Status |
|---|---|---|
| 1. The family engages the doula privately | The resident or their representative invites the doula. The doula follows the facility's visitor policy and any rules it sets for outside companions. | Documented The most common arrangement. See how doulas actually get paid. |
| 2. An organization engages the doula | A facility or its partner hospice runs a volunteer vigil or doula program, or employs a doula. | Documented in some facilities, named below. |
| 3. Models that do not exist yet | A standard contracted doula role across a chain of facilities, or a payer that covers it. | Proposed Nursing homes are not paid for doula services by Medicare or Medicaid. |
Scope check for long-term care
A doula may
- Sit with the resident, talk, read, play chosen music, hold a hand if welcome.
- Take vigil shifts the family cannot cover, within visiting rules.
- With consent, keep distant family informed and help them plan visits or calls.
- Attend a care plan meeting if the resident or representative asks.
- Tell the nurse on duty promptly about any change or sign of distress.
- Help the resident raise a concern with staff or the ombudsman.
Hand to the care team
- Any personal care: bathing, toileting, repositioning, feeding, transfers.
- Any medication question, reminder or assistance.
- Pain, breathlessness, swallowing trouble, agitation, a fall.
- Decisions about hospital transfer, orders or hospice care.
- Suspected abuse or neglect: to the facility's administrator and the state's reporting line; an emergency to 911.
- Pronouncing death and what happens right after: to the nurse and hospice.
How end-of-life care works in these settings
Nursing homes
A nursing home (a skilled nursing facility or nursing facility, in Medicare and Medicaid terms) must meet federal "Requirements for Participation" in 42 CFR Part 483. Near the end of life, three things matter most.
- A care plan. Each resident has a comprehensive care plan written by an interdisciplinary team that includes the attending physician, a registered nurse, a nurse aide and food and nutrition staff, and, where practicable, the resident and their representative, plus other staff or professionals "as requested by the resident."
- Advance directives. The facility must tell adult residents in writing about their right to accept or refuse treatment and to make an advance directive, and describe its own policies for honoring them.
- Hospice by agreement. A nursing home may arrange hospice through a written agreement with a Medicare-certified hospice. Hospice takes responsibility for the hospice plan of care and its services, including nursing, counseling, social work and the drugs and equipment for the terminal illness. The facility keeps providing 24-hour room and board, personal care and nursing, must tell the hospice at once about significant changes or a death, and must name a member of its own team to coordinate with the hospice.
Medicare says hospice can usually be received where a person lives, including a nursing home or assisted living. Medicare's hospice benefit does not cover room and board in a nursing home. The hospice page covers the hospice side in depth.
Staffing realities
Federal rules require "sufficient" nursing staff around the clock, a licensed nurse as charge nurse on each shift, and a registered nurse for at least 8 consecutive hours a day, 7 days a week, unless waived. On many shifts, a small number of nurses and aides cover many residents. That is the gap a doula can respect and quietly help with: not by doing staff work, but by being present so a dying resident is not alone between rounds.
Assisted living and memory care
Assisted living is licensed and regulated by each state, not by federal nursing home rules. HHS's 2015 compendium of state rules notes that residential care settings are licensed and regulated at the state level, and found that of the 40 states requiring training for direct care workers, required hours ranged from 1 to 80. That compendium is from 2015; state rules have changed since. Memory care is usually a unit or specialty license within assisted living or a nursing home. What visitors may do, what staff must do, and whether a facility can keep a dying resident all vary. Learners must check their own state's licensing agency and the facility's written policies.
Home care agencies
At home, families may hire an agency aide. States license these agencies differently. Colorado, for example, has Class A agencies, which may provide skilled services by licensed nurses, nursing assistants and therapists, and Class B agencies, which provide personal care only and may not provide skilled services. A private-duty aide does hands-on personal care under the agency's license and supervision. A doula does not. If the family needs help with bathing, toileting or medications, that is the aide's or nurse's job.
Residents' rights that matter to a doula
These come from 42 CFR 483.10, which applies to nursing homes certified by Medicare or Medicaid. They do not automatically apply to assisted living or home care.
| Right | What the rule says, in plain words | Its limits |
|---|---|---|
| Visitors | The resident may receive visitors of their choosing at the time of their choosing. The facility must give immediate access to family, and to others visiting with the resident's consent. | Subject to reasonable clinical and safety restrictions, other residents' rights, and the resident's right to refuse a visitor at any time. |
| People who provide services | The facility must give reasonable access to anyone providing health, social, legal or other services to the resident. | "Reasonable," subject to the resident's consent and the facility's written visitation policies. |
| Care planning | The resident may take part in planning their care, including naming individuals or roles to include, requesting meetings, and seeing the plan. | The team decides clinical care; the doula is there because the resident asked. |
| Resident and family groups | Residents may organize resident groups, and families may meet together; the facility must give them space and respond to their recommendations. | Staff and visitors attend only at the group's invitation. |
During the COVID-19 emergency, CMS issued special visitation guidance. CMS now marks that memo as expired, so the regulation text above is the reference point. A resident's representative, as the rules define it, can be a person the resident chose or a person with legal authority, such as an agent under a power of attorney or a guardian. That is who gives permission when the resident cannot.
Getting in the door, step by step
- Permission first. The resident, or their representative, invites you and agrees to what you will do. Keep it simple and, if possible, in writing that stays with the family.
- Read the visitor policy. Ask for the facility's written visitation policy. Learn the sign-in, hours for overnight vigils, and infection-control steps.
- Introduce yourself. Ask to meet the director of nursing and the social services staff. Say plainly what you do and do not do: "I'm a non-clinical companion the family has asked to be here. I don't do any hands-on care or medications. I'll let the nurse know right away if I notice any change."
- Ask their expectations for outside companions. Some facilities ask outside caregivers or companions to register, sign an agreement, show proof of immunizations, pass a background check, attend a short orientation, or carry liability insurance. Ask, and comply; do not assume.
- Know who to tell. Learn who the charge nurse is on each shift, and who the hospice nurse is if hospice is involved.
If the facility treats you as a volunteer or contractor, federal rules require it to train volunteers and contract staff consistent with their expected roles, including residents' rights and abuse prevention. That is a sign of a formal role (rail 2), with its own supervision.
What a doula adds that staff rarely have time for
| Facility reality | Doula response |
|---|---|
| Staff cover many residents; no one can sit for hours. | Vigil shifts, arranged with the family, so the resident is not alone between rounds. Call the nurse for any change. |
| The resident has no family nearby. | Steady presence; with consent, short updates to distant family and help setting up calls. |
| Care plan meetings are short and technical. | Help the family prepare questions and remember what was said. Speak only when invited. |
| The room is loud or clinical. | Within facility rules: chosen music, a familiar blanket or photo, quiet voices, dim light. |
| Advanced dementia: the resident cannot say what they need. | Calm presence, familiar songs or stories, gentle touch if welcome. Report signs of possible pain to the nurse. |
| Staff grieve too, and move to the next resident. | A kind word. Never judge the staff or the facility to the family. |
| A problem seems to be going unaddressed. | Help the resident or family raise it with the charge nurse or administrator, then the ombudsman if needed. |
Dementia-informed presence
The National Institute on Aging notes that in the final stages of Alzheimer's disease, people may show pain through groans, sighs, grimacing when touched, agitation or guarding a part of the body. Staff and the health care team decide what to do about pain. NIA also says that even in advanced dementia, a person may benefit from connection: a story, photos, touch, music or sounds of nature, and simply someone present. That is doula work.
When something seems wrong: the Long-Term Care Ombudsman
Every state has a Long-Term Care Ombudsman program, authorized by the federal Older Americans Act. Ombudsmen work to resolve problems with the health, safety, welfare and rights of people who live in nursing homes, assisted living, board and care homes and similar settings. They identify, investigate and resolve complaints made by or for residents.
Ombudsman work is resident-directed. Under federal rules, the ombudsman discusses a complaint with the resident, asks for the resident's consent to investigate, and follows the resident's wishes about how to resolve it (or the representative's, if the resident cannot consent). Nursing homes must post the ombudsman's contact information.
How a doula raises a concern
- Start with the resident: "Would you like me to help you tell someone about this?"
- Then the charge nurse or social worker, then the administrator or director of nursing.
- If it is not resolved, help the resident or family contact the ombudsman. You may share what you saw; you do not investigate, interview staff or collect evidence.
- If someone is in immediate danger, call 911. Suspected abuse or neglect can be reported to the state survey agency or adult protective services, whose contacts facilities must post.
Documented examples
These are real programs described publicly by the organization or a trade publication. We have not evaluated them.
- Documented James L. West Center for Dementia Care (Fort Worth, Texas) runs an "11th Hour" program, started in 2021, in which trained volunteers aged 22 to 88, including staff, family and community members, sit with residents in their last days. LeadingAge (May 30, 2024) reported 18 active volunteers, a two-hour training twice a year that includes dementia communication, and 82 families served.
- Documented PeaceHealth Hospice (Vancouver, Washington): the Catholic Health Association reported in July 2025 that its No One Dies Alone program extends to hospice and community settings, including assisted living and skilled nursing facilities.
- Documented Franke Tobey Jones, a senior living community in Tacoma, Washington with assisted living, memory care and skilled nursing, announced an end-of-life doula program on July 1, 2023. Its doulas are trained volunteers who offer non-medical support to residents and families.
- Documented Providence Place, a Lifespark skilled nursing community in Minneapolis, posted a part-time "End of Life Doula" job on May 23, 2024, requiring completion of an end-of-life doula program. The posting closed on June 7, 2024; we do not know if the role was filled or continues.
- Documented Goodwin Hospice, part of the nonprofit senior living organization Goodwin Living in Virginia, told Hospice News (November 2023) that it works with an outside doula provider for hospice patients and families, funded by philanthropy. This is a hospice arrangement, not a facility benefit.
Evidence note: a 2022 scoping review found death doulas' roles are still evolving and mostly unregulated, with little evidence about their impact.
How a facility could bring in a doula formally Proposed
Three paths, from lightest to heaviest. None is paid for by Medicare or Medicaid as a doula service.
- Volunteer program. Doula-trained volunteers join the facility's volunteer program for vigils, like the documented examples above. The facility trains, screens and supervises them.
- Contracted companion role. The facility contracts with a doula or doula group for defined non-clinical companionship, paid from its own budget or philanthropy.
- Family-hire policy. The facility writes a clear policy for doulas that families hire: registration, orientation, what they may and may not do, and who they report to.
Safeguards before any of these
- A written scope: no personal care, no medications, no clinical judgments, no documentation in the medical record unless the facility defines it.
- Screening, orientation and training that match the role, including residents' rights, abuse prevention, infection control and privacy.
- A named staff supervisor, and a clear line to the hospice team when hospice is involved.
- A compliance review. Under the Anti-Kickback Statute, no payment may be tied to referrals of residents or of federally paid business, in either direction. A hospice or doula must not offer a facility anything of value to win referrals.
Why it might not work: no payer covers it; turnover makes supervision hard; and if staff see doulas as filling staffing gaps, the role drifts toward care work it must not do.
Worked example: a vigil in a memory care unit
A man with advanced dementia is on hospice in a memory care unit. His only son lives overseas. The son engages a doula privately and asks her to sit with his father for the nights ahead.
One reasonable path
The doula confirms with the son, who is his father's legal representative, what he wants. She asks the facility for its visitor and overnight policy, meets the nurse manager and the hospice social worker, and completes the orientation the facility asks for. On her shifts she plays the music the son says his father loved, speaks softly, and tells the nurse when he seems restless or grimaces. With the son's consent, she sends him a short update each morning. She never repositions him or offers him food or water; she asks the aide or nurse.
The trap: trying to "fix" his restlessness herself, or criticizing the night staff to the son.
This example is invented for teaching. It is not based on a real person or facility.
Questions to ask
- To the resident or representative: "What would you like me to do here, and who may I talk with about you?"
- To the director of nursing or social services: "What do you expect of outside companions? Do I need to register, sign anything, show immunizations, or attend orientation?"
- "Who should I tell, on each shift, if I notice a change?"
- "Is hospice involved, and who is the hospice nurse and social worker?"
- "Can I join the care plan meeting if the resident asks me to?"
- For assisted living or home care: "Which state rules and which agency policies apply to someone in my role?"
- To yourself: "Am I being asked to do care work, or am I being offered anything for referrals?" If yes, stop and ask.