Hospice’s ‘civil war’

PART 4 of 5

By Susan Brinkmann
CS&T Correspondent

The hospice industry began in a London hospital just after World War II.
Dame Cicely Saunders, a nurse and devout Anglican, was working as a medical social worker when she met a Jewish emigre named David Tasma.
Tasma, who was alone in the world, was dying. Saunders began to visit him daily, and during their discussions she received a first-hand look at the needs of the dying. She began to realize that people need more than just physical pain control. They need spiritual, psychological and social pain control as well.
When Tasma died, he left Saunders £500 to begin her work, which eventually became the hospice industry.
Traditional hospice care allows patients to die naturally, at home, surrounded by their loved ones. It is the antithesis of everyone’s worst nightmare — dying at the hands of uninterested medical personnel while attached to a roomful of cold metal machines.
“The task of medicine is to care even when it cannot cure,” according to the U. S. Conference of Catholic Bishops’ Ethical and Religious Directives for Catholic Health Care Services. The bishops’ directive goes on to say compassionate, end-of-life care requires that all patients “be kept as free of pain as possible, so that they may die comfortably and with dignity, and in the place where they wish to die.”
Unlike the British system, hospice care in the United States requires that patients’ diagnoses indicate they have fewer than six months to live, and most patients must agree to give up all curative medical care. Patients are treated by a team of professionals that includes visiting nurses skilled in pain management, as well as social workers and pastoral care workers, who help patients and families face an upcoming death.
The American hospice industry also differs from its British parent in that it’s founder, Florence Wald, M.S.N., is an open advocate of euthanasia.
Wald told the Journal of the American Medical Association in 1999: “I know that I differ from Cicely Saunders, who is very much against assisted suicide. I disagree with her view on the basis that there are cases in which either the pain or the debilitation the patient is experiencing is more than can be borne, whether it be economically, physically, emotionally, or socially. For this reason, I feel a range of options should be available to the patient, and this should include assisted suicide.”
Because of that key difference, “a civil war has been waging within hospice [care] from the very beginning,” said Ron Panzer, a former Michigan hospice nurse who founded the Hospice Patients Alliance.
Wald’s espousal of euthanasia may be why the American hospice industry has forged alliances with pro-euthanasia groups. Perhaps the most widely publicized evidence of the link between the euthansia movement and hospice is the Terri Schiavo case. George Felos, the attorney arguing to have food and hydration removed from the 41-year-old cognitively disabled woman, is a prominent right-to-die attorney who once served as board chair of the Hospice of Florida Suncoast, which runs Hospice House Woodside, where Schiavo is being kept.
Last Acts Partnership, the largest coalition of hospice organizations in the country, is the result of a marriage between two organizations called Partnership in Caring and Choice in Dying — the latter was originally known as the Euthanasia Society of America, according to Panzer.
A financial advantage for the pro-euthanasia philosophy entered the picture in 1983, when Medicare began paying for hospice care; the result was a four-fold increase in for-profit hospice associations within a 10-year period. The number of patients jumped from 100,000 in 1983 to almost 900,000 by 1998.
“For years, hospice has bragged about the financial savings to the state and federal budgets by using hospice rather than traditional, acute hospital-care,” Panzer said.
“The largest expenditures under Medicare are during the last two months of life,” he said. “If you take people in the last two months of life, and put them into hospice, there are millions and billions of dollars in saving[s], compared to acute hospital-care. And then, if you actually kill them, there’s even more savings.”
Medicare fraud in the hospice industry eventually attracted the government’s attention. The U.S. Department of Health and Human Services issued a formal advisory bulletin about the problem in 1995.
Seven years later, Robert Davis wrote in USA Today: “It’s easy to abuse the system. The patient always dies and no one can complain that a hospice program should have saved the life.” But Davis said some families were beginning to come forward to complain about negligent care and demand more oversight of the industry.
Pro-euthanasia groups praise the traditional hospice concept, but say they want assisted suicide to be included as an option for patients who do not want to suffer excruciating pain.
What these groups do not tell the public is that advances in palliative care have made almost all pain potentially curable.
Bishop Elio Sgreccia, President of the Pontifical Academy of Life, recently said: “Everyone knows that in our time almost all pain has become ‘curable,’ palliative and analgesic treatments, thanks be to God, promoted throughout the world . . . succeed in maintaining the humanity of treatments . . . and the serenity of death.”
Where the culture of death exerts its influence is in the potential for the misuse of pain-killers to hasten death, rather than merely to control pain.
This practice is even considered acceptable by some ethicists and doctors, who say they consider “terminal sedation” (TS) to be a legal alternative to assisted suicide. TS is defined as a deliberate “termination of awareness” — usually with morphine — that renders the patient unconscious, so that all treatment, including food and water, can be withdrawn.
“That they should die in comfort is clearly the goal — and I would argue the legitimate goal — of terminal sedation,” Erich Loewy, a medical ethicist at the University of California-Davis, contends in “Terminal Sedation, Self-starvation and Orchestrating the End of Life.”
This is not the opinion of hospice founder Dame Saunders. She has said the goal of hospice care is “to make it possible for people who are dying to live fully until they die.”
Nor is it the Vatican’s belief.
Its 1994 Charter for Health Care Workers specifically warns against depriving the dying of the “possibility of living his own life, by reducing him to a state of unconsciousness not worthy of a human being. This is why the administration of narcotics for the sole purpose of depriving the dying person of a conscious end is a truly deplorable practice.”
According to Terre Mirsch, Vice President of Holy Redeemer Home Health and Hospice Services, a good hospice should do a lot more than administer pain medication: “Symptoms come from not just physical manifestations, but from the psychological and spiritual implications of illness and the dying process. We need to treat the whole person, not just focus on physical care or giving medications.”
Holy Redeemer’s team approach addresses all of a patient's needs, so that “patients are able to die comfortably,” Mirsch said. “They are able to die with dignity, and don’t feel the need to request interventions such as assisted suicide and euthanasia.”
During her 15 years in hospice work, Mirsch said, she found that what patients fear most is dying in pain: “Once they see that we’ll do everything in our power to alleviate their pain and suffering through appropriate medical and emotional care ... people want to live, and are able to live as fully as possible. They’re able to spend meaningful time with friends and family, and focus on what’s really important.”
Mirsch recommends that families seeking hospice care take a careful look at a service’s mission statement. A good hospice should be able to provide service in a variety of settings, in order to accommodate a patient’s needs throughout the course of his or her illness. She said patients and their families should ask about after-hours services, and should not wait until a crisis to look for a hospice.
For more information, visit www.hospicepatients.org or contact Holy Redeemer Home Health and Hospice Services at www.holyredeemer.com or 1-800-818-4747.

Contact Susan Brinkmann at fiat723@aol.com or (215) 965-4615.

“Declaration on Euthanasia” issued in 1980 by the Sacred Congregation for the Propagation of the Faith:

“The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love — the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.”