The Legacy of Jack Kevorkian.

Lewis M. Cohen at HuffPo on the legacy of Jack Kevorkian:

While there's little doubt that he has been a galvanizing figure on both sides of the right to die movement, when it comes to his actual role in alleviating suffering, the reality is far murkier. Kevorkian's legacy has long threatened the ongoing and truly compassionate efforts of hospice and palliative medicine, a medical specialty that focuses on symptom and pain management for the terminally ill. Over the past decade, widespread acceptance of palliative care has contributed to a dramatic change in how people die. Even in America's intensive care units -- our country's most medically aggressive settings -- more than three-quarters of an estimated 400,000 deaths are now preceded by treatment limitation decisions. In 2008, 1.45 million Americans died while making use of hospice services, and according to Dr. Steven Miles, a Professor of Medicine at the Center for Bioethics at the University of Minnesota, fully eighty-five percent -- or approximately two million -- of the 2.4 million deaths occurring annually in the United States medical system are preceded by a structured decision to limit life-sustaining treatment. Throughout the nation it is now both legal and ethical for people to refuse to initiate or to discontinue life-support treatments.

Far from being their leader, palliative care practitioners consider Kevorkian to be a dangerous distraction. Yet despite this disavowal, palliative care is sometimes maligned -- primarily by a coalition of sanctity of life and anti-euthanasia organizations -- because of the legacy of Dr. Death. In the early 1990s, Kevorkian came to the public's attention after retiring from his profession as a pathologist -- a doctor who provided no clinical care, but instead performed autopsies on the dead -- to become a physician-assisted suicide activist. However, in a notorious broadcast of the CBS program, 60 Minutes, Kevorkian showed the world that he had shifted from physician-assisted suicide to active, voluntary euthanasia -- injecting a patient suffering from Lou Gehrig's disease with a fatal combination of three medicines -- a crime for which he received an eleven to twenty year sentence for second-degree murder.

Great News! Palliative Care Becoming More Accessible.

UPI reports that a new study shows a marked increase in the accessibility of palliative care programs in hospitals. From the story:

Dr. Diane E. Meier, director of the non-profit Center to Advance Palliative Care, said the number of palliative programs in U.S. hospitals with 50 or more beds increased from 658, or 24.5 percent, to 1,486, or 58.5 percent, a 125.8 percent increase from 2000-2008.

"Palliative care programs are transforming care of the seriously ill in hospitals," Meier says in a statement. "It addresses the fragmentation of the healthcare system and puts the focus back on communication with the patient and family. Hospitals today recognize that the cost of not providing this type of care is just too high."

The analysis was conducted in conjunction with the National Palliative Care Research Center using hospital data from the American Hospital Association annual survey database.

Large hospitals and not-for-profit hospitals were more likely than other types of hospitals to have a palliative program, Meier says.

The ER and Cancer Patients.

Suzana Markowski has a new post at Pallimed about emergency room use and cancer. Her post looks at a new study of ER visits and examines ways to better treat end of life issues. Here's a clip:

We know already that most people want to be at home with family at the end-of-life, we also know that most end up in hospital or institution. We have hypothesized that increasing access and enrollment to hospices might help people meet this goal. This article seeks to understand how frequently and why patients with end-stage cancer choose to go to the ER.

So this begs the question… what percentage of patients with cancer visit the emergency room during the last 6 months and 2 weeks of life?
Of the 91,561 patients who died of cancer between 2002 and 2005, 84% of patients visited the ER in the 6 months prior to death and 34% of patients visited in the last two weeks before death. They outline the principle reasons for emergency room visits: primary cancer (mostly lung cancer), uncontrolled symptoms (pain, dyspnea and other non-pain symptoms), caregiver fatigue, and infection.
Top reasons for ER visits among patients with cancer:

While many of the patients studied ended up admitted to hospital, the authors – and I believe, rightly so – postulate that most may have avoided acute-level care had the quality and quantity of care had adequately supported the needs of both patient and caregiver. Instead of emergency room care, most of these patients required “either additional support to remain at home or direct transfer to a palliative care unit or residential hospice.”

Barbera and colleagues suggest that “comprehensive and coordinated” palliative care could serve the needs of most of these patients and their caregivers and meet this demand for quality and quantity of care, allowing patients to have symptoms tended to at home, in clinics, or in in-patient or residential hospice facilities.

How Do We Productively Talk About Death?

From Patrice Villars at GeriPal, a discussion of how palliative care practitioners - and the medical profession - talk about death. She starts with a reference to a talk she attended at the recent HPNA/AAHPM conference by Diane Meier, MD titled “Update on National Palliative Care News: How the Big Picture Affects You.”

My first reaction to the post is to disagree. Much like religion, death tends to be discussed in society in a bifurcated way where all nuance and practicality - and actuality - are lost. It's either a screaming, scary nasty thing to avoid at all costs or a saccharine-tinged "passing" into a "better place. (With religion, the portrayals are of nutso crazy bible-thumpers or benign do-gooders with the best of intentions.) But with both death and religion, neither portrayal or language-set is wholly accurate/true.

My other - new - hat is editor of TheRevealer.org (relaunching in the next few weeks). The site looks at how religion is portrayed in the media. And I think the same work toward nuance and understanding there regarding religion reporting is applicable to death "reporting." And so, if avoiding the exaggerations of death and getting at the practicality, complications, nuance and inevitability requires readdressing how we discuss death, then yes, examining the terms used is important and beneficial. But if we're devoted to creating a lexicon about death that further removes us from its actuality, then I say we're on the wrong path.

Here's a great clip, though I recommend you go to the site and read the rest of it, and the comments too:

The new (to me) hot word in the political arena is “optics”. It’s all about how you see things - perception. Perception is in the eye of the audience. (Kind of like pain or shortness of breath is what the patient says it is.) We want and NEED to have a relationship with our patients and families who are part of the general public. We need them to perceive us as helpful and valuable both to serve them and to promote our vision of a holistic health care environment that matches patients’ preferences with appropriate care. So why do our patients/families, through the media and through our work, often NOT see us as helpful and valuable, but, as my son once proclaimed me, as “The Mistress of Death”? What, we must ask if we want to sustain a future in this relationship, is our part?

Dr. Meier observed that we use language that associates palliative care with dying. Consistently. Language is important. Language creates perceptions and (may) define our relationships with the people we care about most. Consider that the tiny line in the proposed health care bill allowing physicians to be reimbursed for having a conversation every 5 years with their patients about advance directives DIED because of optics. It was perceived (used, twisted, misconstrued) by a few clever politicians that physicians were going to talk about dying and (logically, of course) talk people into dying. They quickly conveyed this idea to the general population, OUR audience – our audience who votes. Language. Optics.

Our audience – patients and families – often don’t want to hear about dying. Death and dying is scary. Scary equals reactionary sound bites (i.e. death panels) that can dash any hope we have of reasonable reform and ongoing open relationships. (Ex. Advance directives talks with your physician = dying = fear = death panel = killing Granny and babies with Down’s syndrome). And guess what other words also equal death to our audience? Terminal. Advance directives. End-of-life. Hospice. Yes, and even bereavement. As long as the majority of our patients/families (to say nothing of our health care colleagues) associate palliative care with dying, they will not have access to our services.

Whoa, this is a lot to take in. You mean don’t use the words we have been using for decades to demystify the fear and denial of death in our culture? Isn’t this who we are? What about the movement we have come to birth, nurture and protect? Really, stop using those words?

On the other hand, if these words cause others to retreat from our services, how does it serve either of us? Does rubbing someone’s nose in something we feel is important make them want to be our friends? Probably not.

Decline in Hospice Stays and Duration?

Howard Gleckman of the Urban Institute writes at Seattle's Local Health blog that hospices are seeing fewer patients and shorter stays and suspects it caused by doctors who don't refer patients early enough and misconceptions about hospice care:

Suddenly, many hospices are admitting fewer patients. Others are increasingly caring for people for just days or hours before they die. The result: cash-strapped hospices are cutting back on nurses and aides, and patients are missing out on critical end-of-life care.

It is not clear why it’s happening, but some hospice officials blame both a bad economy and Medicare rules that unintentionally discourage doctors from referring all but those who are about to die.

Even though hospices have been operating in the U.S. for three decades, they remain widely misunderstood. Hospices provide medical care, pain management, spiritual and social care and volunteer support for those nearing the end of their lives. And their patients often live longer than if they were still receiving full-blown medical treatment.

Nearly all hospice care is paid by Medicare, but unlike most providers, hospices are paid a fixed daily rate (on average about $140-a-day for home care patients). If a hospice provides care for less, it keeps the difference. If a patient requires very costly care, the hospice can lose money.

The number of patients served by hospices increased from about 1 million in 2004 to nearly 1.5 million in 2008, while the number of hospices grew from 3,600 to almost 5,000. Most of this explosive growth has been driven by for-profit companies.

But in recent months, hospice officials have seen a downturn. In some states, such as Oklahoma, heavy competition has forced consolidation, and at least 10 hospices have closed in the past year.

Elsewhere, hospice officials blame the bad economy. Patients who have lost jobs–and insurance—may be waiting longer to visit the doctor and consequently are diagnosed with terminal illnesses at a very late stage.

Some hospice executives say the poor economy may also be driving doctors to hold on to patients longer.

Here’s why: Once a patient joins hospice, she’s likely to see her physician far less often. Her doctor can usually order tests and treatments only to keep her comfortable, and not to try to cure her terminal disease.

And while it may still be appropriate for, say, cancer patients to receive costly drugs or even radiation therapy to relieve pain, hospices must pay for these treatments out of their daily Medicare rate.

That inevitably can create tension between the hospice and the physician.

And it may add up to less money for doctors at a time when they are already feeling squeezed. One physician I spoke to strongly rejected this argument, insisting that declining compensation does not slow referrals.

But another—an oncologist who frequently refers to hospice—acknowledged the problem. “There is a financial deterrent,” she says.

At the same time, new Medicare rules may be further discouraging physician referrals. Medicare has begun cracking down on a handful of hospices that are making big profits by taking on chronically ill, but not terminally ill, patients.

While hospice patients are normally expected to have six months or less to live, some hospices have many on their rolls for a year or more.

In one attempt to stop this practice, Medicare now requires doctors to write a brief narrative describing why a patient is appropriate for hospice. Trouble is, says one hospice official, “We’re getting a lot of pushback” from doctors.

In 2008, more than one-third of patients were enrolled in hospice for a week or less, and some organizations are seeing the number of short stays increase, perhaps because these requirements may be making already reluctant doctors even less willing to refer to hospice until their patients are actively dying.

Mark Murray, president of the Center for Hospice and Palliative Care in South Bend, Ind., says that in the past year, eight percent of his referrals died before they could even be admitted, and 20 percent died within 48 hours.

Those last-minute decisions put enormous financial pressure on hospices and make it impossible for patients to get the full benefit of end-of-life care.

These disincentives come on top of a long-standing reluctance on the part of many doctors to even talk about hospice. In a 2009 study, more than half of patients with stage IV lung cancer said their physicians never even raised the option.

I am a huge fan of hospice: My wife is a hospice chaplain and both my father and father-in-law were hospice patients. These organizations are a model for coordinated care that other health care providers would do well to copy.

But doctors need to be persuaded to use hospice. And that may mean changing a payment system that may be discouraging them from using this valuable service.

Church of England and Dying Matters Coalition.

From Britain, where the struggle over patients' end of life rights is as intense as our own here in the US, news of the Church of England's joining with other organizations to form Dying Matters Coalition, an organization committed to making "a good death" the norm in health care. The organization is headed by the National Coalition of Palliative Care (NCPC). From the Church of England's website:

The Church of England has joined more than 1,000 organisations in the national Dying Matters Coalition. Led by the National Council for Palliative Care (NCPC), working closely with the Department of Health (DH) and other key stakeholders, the coalition aims to promote public awareness around death, dying and bereavement.

The Bishop of Southwark, the Rt Revd Tom Butler, vice chair of the Archbishops' Council's Mission and Public Affairs Council, said: “I welcome the Dying Matters initiative as an important contribution to the debate about dying and death. The advances in palliative and end of life care have been helpful in improving the quality of life of those who are dying and their families, and I hope that this new coalition will bring help and information to many people.”

Hilary Fisher, Director of the Dying Matters Coalition, said: “We are delighted that the Church of England has joined the Dying Matters coalition. For too long, issues of death and bereavement have been perceived as too big or scary to talk about; the ensuing silence has resulted in isolation and confusion among dying people and their families. Openness, conversation and communication are vital in addressing this.

“Dying Matters has over a thousand members, including community groups, healthcare bodies, private individuals and groups representing a range of faiths. The Church of England’s voice is welcome in a conversation that should continue across all sections of our society."

The overall mission of the coalition is to make a ‘good death’ a normal expectation, and for dying, death and bereavement to be accepted as a natural part of everybody’s life cycle. An agreed programme of planned collective action is to be formulated by the coalition to ensure that progress is made as a key part of the implementation of the Government’s End of Life Care Strategy for England.

More information on Dying Matters is available here.

Details of the End of Life Care Strategy are available here.

Legal Questions Answered For End of Life Care.

The American Bar Association, in coordination with the National Hospice and Palliative Care Organization, has issued a new document that is meant to aid patients and their care-takers when facing legal issues in preparation for end of life.

The document can be found here and highlights such difficult issues as how to pay for the health care you need, what are a patient's rights, and planning how to manage your money and property.

I hope the Guide for the Seriously Ill gets some good distribution. One of the more challenging aspects of facing terminal illness is not just knowing how to tackle legal challenges but knowing exactly what those legal challenges are. Here's an excerpt from an article at Senior Spectrum:

Knowing what vital steps to take to get your financial and legal affairs in order when confronted by serious illness just became easier thanks to a new guide released by the American Bar Association (ABA).

Seniors and family members facing the onset of a life threatening illness or injury are often unaware of how to get their affairs in order to protect themselves and their families.

“The Legal Guide for the Seriously Ill” — a project by the ABA Commission on Law and Aging commissioned by the National Hospice and Palliative Care Organization (NHPCO) — was designed for both the seriously ill individual and those caring for someone who is seriously ill.

The guide explains “Seven Key Steps” in a brief, clear way while offering additional tips and resources for readers looking for more detailed information and guidance.

“‘The Legal Guide for the Seriously Ill’ is a great resource for anyone facing a serious illness,” noted ABA president Carolyn B. Lamm. “The book provides critical tools that help readers understand their options, make informed decisions and minimize some of the anxiety they may be feeling about their financial and legal affairs at this stage of life.”

Development of the new guide was prompted by current societal issues and concerns facing many Americans, such as paying for health care, managing health and personal decisions, and patient rights.

“The Legal Guide for the Seriously Ill” also explores recent legislative and regulatory changes to give users a thorough understanding of where they stand when making important decisions.

The guide is expected to fill an important gap in resources for many Americans.

Top 50 Hospice, Elder Care Blogs.

The Health Herald blog has done us a favor by listing their pick of the top 50 hospice and elder care blogs:

General Hospice Care Blogs

Get a general idea of what hospice care is all about, and learn more about your options and the possibilities.

1. Hospice Blog: This offers information on hospice care, and the fight for quality care.
2. Hospice Physician’s Blog: Learn about hospice and how it works from a doctor working in the field.
3. Hospice and Nursing Homes Blog: Hospice practices, insights, research, news and issues.
4. Hospice and Caregiving Blog: News, information and more surrounding hospice care, as well as information for caregivers.
5. Home Care Law Blog: This blog focuses on legal issues surrounding home hospice care.
6. Alive Hospice Blog: Learn more about hospice care and end of life issues from a hospice provider.
7. Hospice: Learn more about hospice care, and what goes into it, as well as what to expect.
8. Life as a Hospice Patient: This is an interesting firsthand account of a hospice patient, and what hospice care means to her.
9. Compton Hospice: Get a view of hospice care from a British perspective.

Elder Care Blogs

Find out about senior living, and how hospice care can fit into the picture. These blogs also include information about finding hospice care and making the most of it.

10. AARP: Read the blog from the AARP, including coverage of issues related to health care, hospice care and end of life.
11. Eldercare ABC Blog: Learn about the essentials of elder care, and find valuable resources and support.
12. Elder Care Diary: Keep up with the day to day activities of a family involved in elder care.
13. ElderCare Expert: Get useful insights and helpful hints from someone who has been involved in senior care for a long time.
14. The New Old Age: A look at the way we age in these modern times. An interesting look at hospice, assisted living and other related issues.
15. Senior Care Blog: Learn about issues associated with aging, as well as elder health, and information on long term home care.
16. Choosing Elder Care: A review of different options in elder care, and helpful information and resources.
17. Elder Care Blog: Learn about issues that come up in elder care, as well as issues relating to end of life.

Death Care Blogs

Get insight into the end of life process, and learn about how hospice care can fit into this.

18. Death Care Law Blog: Keep up with what your rights are in end of life, and find information about pre-need issues.
19. Death Care Law: Another interesting legal blog focusing on death issues.
20. How We Die: An interesting look at stories from people regarding death, and how we view death as a society.
21. Medical Futility Blog: Get a tongue in cheek look at the issues — judicial, legislative and political — surrounding the end of life.
22. The Good Death: Bringing about death with dignity, and a look at how society deals with death.
23. Death Care: Looks at issues surrounding death, as well as provides resources to help you make more informed decisions.

Pain Management Blogs

One of the important functions of hospice care is to provide pain management. Read about different options and treatments, as well as additional information on palliative care.

24. Palliative Care: This About.com blog focuses on pain management, as well as easing some of the other symptoms often associated with the approach of life’s end.
25. GeriPal: This blog focuses on palliative care and pain management in the elderly. Offers helpful posts and insight into different medicinal options.
26. Pallimed: A look at the role palliative care plays in the way hospice care handles end of life.
27. Palliative Care Success: Explores the successes seen in pain management and symptom control as part of hospice care.
28. Pain Management Blog: Focuses on different advances in pain management.
29. Chronic Pain Management: Learn how to deal with chronic pain, and help others deal with it.
30. St. Christopher’s Blog: Malcolm Payne: This blog is offered up by St. Christopher’s Hospice in London, and provides insight into palliative care and social care for end of life.
31. Palliative Care Bulletin: Get the latest news alerts about end of life care.

Nursing Home Blogs

While not exactly hospice care, nursing homes can provide many of the same services. Learn about different nursing home options and possibilities, as well as preparation for long-term care.

32. My Better Nursing Home: Get an idea of what better nursing home care could look like, and how we might be able to get there.
33. My Elder Advocate: This blog deals mostly with issues related to nursing homes, and your rights with regard to them.
34. The Nursing Home Administrator: Get an insider’s view of how a nursing home is run from a nursing home administrator in Indiana.
35. Jonathon Rosenfeld’s Nursing Homes Abuse Blog: This blog focuses on nursing home abuses, and shows you how you can get better care from your nursing home.
36. South Carolina Nursing Home Blog: News and information related to nursing homes, especially those in South Carolina.

Caregiver Blogs

Being a caregiver for someone approaching their end of life can be difficult. Learn about others’ experiences and find sources of strength and support.

37. Caregiver List: Helpful information on where to find information about different facilities, training and other items.
38. Inside Elder Care: Get a firsthand look at caring for others. This blog is written by someone who is caring for his aging mother.
39. Lasting Tribute: This isn’t just about the elderly. You can leave stories and messages about anyone who has died. But the blog includes plenty of interesting stories from caregivers and others.
40. Risa’s Pieces: Learn about what it’s like to be a hospice caregiver from this compassionate professional.
41. Caring for Aging Parents: Learn about how you can cope with caring for aging parents, and find support as well as answers to your questions.
42. Caregiver Support Blog: Find support in your position as caregiver, and read about others.
43. The Caregiver’s Blog: Learn about being a caregiver and find support from others in a similar position.
44. Caregiving: Tips and hints for caregivers, especially those who are caring for people with Alzheimer’s.

Nurse Blogs

Get professional insight from health care professionals who have some experience with end of life.

45. Dethmama Chronicles: Follow the adventures of this end of life nurse. Includes some funny insights and more.
46. Midwife for the End-of-Life: Get accounts of what it’s like to be a nurse caring for those who are near death.
47. code blog: This nurse shares her experience as an ICU nurse, as well as insights on end of life.
48. River of Life: Notes of a Hospice Nurse: This video offers a look into life as a hospice nurse.
49. A Hospice Nurse’s Story: This post on from the Center to Champion Nursing in America offers a poignant look at what it’s like to care for others in a hospice setting.
50. Minnesota HomeCare Association’s Nurse Consultant BLOG: Get an idea of what is going on in the world of home care nursing.

What Paradox? Patients Nor Doctors Want To Plan For Death.

Dr. Drew Rosielle at PalliMed gives another angle to the issues I've been thinking about since coming across an article, noted below, on a new study about doctor's conversations with their patients about end of life care options.

Rosielle writes that a recent survey of patients provides paradoxical answers to questions about their knowledge of end of life care choices and tools:

Only 5 patients reported a discussion about ADs with their oncologist. When they asked patients if they would like to discuss ADs with their oncologist, only 23% said they would (this is similar to the finding in the study 10 years ago). When, however, they asked patients which, of all their doctors, they would prefer to discuss ADs, a plurality said their oncologist (48%). That is, if they have to do it, they'd prefer their oncologist. Notably the vast majority of patients (87%) thought that physicians admitting a patient to the hospital should ask about ADs (they indicated this was not only ok but an important thing to do). Thus, the title of their article, and this post - 'Paradoxes in ACP....'

(They also asked patients about knowledge of hospice care and palliative care. 21% of patients reported knowledge of 'palliative care' vs. 81% for 'hospice care,' and hardly anyone said they knew anyone who had received palliative care.)

From outside the medical world looking in, I think there are a few factors here that add up to no paradox at all: patients don't want to talk about or plan for their deaths; doctors are seen as authorities, patients expect them to guide or inform of medical choices and patients follow their cues; doctors too don't want to talk about death either.

An article in the New York Times yesterday highlighted a new survey of doctors that asks when patients should be told a fatal prognosis, asked about a DNR (Do not resuscitate order), informed of hospice and palliative care, or asked about their death-site preferences.

Time's Denise Grady reports:

Dr. Nancy L. Keating, the first author of the study and an associate professor of medicine and health care policy at Harvard, said not much was known about how, when or even if doctors were having these difficult talks with dying patients. But she said that her research team suspected that communication was falling short, because studies have shown that even though most people want to die at home, most wind up dying in the hospital.

The researchers surveyed 4,074 doctors who took care of cancer patients, instructing them to imagine one who had only four to six months left, but was still feeling well. Then the doctors were asked when they would discuss the prognosis, whether the patient wanted resuscitation or hospice care, and where he or she wanted to die.

The results came as a surprise: the doctors were even more reluctant to ask certain questions than the researchers had expected. Although 65 percent said they would talk about the prognosis “now,” far fewer would discuss the other issues at the same time: resuscitation, 44 percent; hospice, 26 percent; site of death, 21 percent. Instead, most of the doctors said they would rather wait until the patients felt worse or there were no more cancer treatments to offer.

Doctor's need to take the lead in discussing end of life options with terminal and elderly patients. Their patients are waiting for them to do so.

PalliMed Grand Rounds Summary of Blogging.

Christian Sinclair has a new summary of recent palliative and hospice blogging - and tweeting. Catch it here.

Most helpful is a list of active palliative and hospice blogs. Find it here.

Doctors' Role Drift and End of Life Care.

Tim Cousounis at Palliative Care Success makes an interesting observation about "role drift" and the challenges faced by doctors, palliative doctors and hospice organizations when coordinating patient care:

I've been intrigued recently by the spate of articles and seminars concerning themselves with the relationships between physicians and hospitals. Of course, hospital-medical staff relationships have been contentious for years, and consultants advising hospital executives on the most effective ways to align physician objectives with hospital goals is hardly a recent development. So, what do I find intriguing? That similar concerns are surfacing with greater frequency among hospices and palliative medicine physicians, as hospices build their medical staffs and expand the role of physicians within the hospice's clinical and administrative activities.

What we're seeing can best be described as role drift, where there is a disconnect between what the physician sees as his/her role, and what the executives and/or other clinical staff see as the physician's role. Such role drift is magnified in those palliative care organizations where resources are strained. I don't mean to oversimplify, but one will generally find fractious relationships in organizations where the HPM physician does not have:
-Clear roles, responsibilities, expectations and accountabilities
-Well-established performance measures and standards
-Performance management system that tracks performance and offers feedback.

I'm curious to hear your experiences, and what methods you've used to build a high-performing hospi

ce medical staff.

Blogging Hospice.

Don't miss Judi Chamberlain's blog, "Life as a Hospice Patient" for a unique perspective on hospice care, one that we seldom seen blogged.

via PalliMed.

Palliative Blogging.

Death Cab for Cuties rounds up your best palliative blog!

The Benefits of Hospice.

As I prepare to begin my own hospice training and volunteering, I read Jane Brody's column with curiosity and sober preparation. I saw her speak at the Compassion & Choices conference in DC in October. She was wise and lovely. You can find the entire article here. Here's a clip:

Hospice workers never know what they may find when they enter the homes of people whose doctors expect them to die within six months. But they are prepared to handle almost anything and have a team of specialists to call upon when needed: doctor, nurse, social worker, spiritual care counselor, bereavement counselor. The home hospice service is but a phone call away 24 hours a day, 7 days a week. The needs of patients and families are met within hours, if not sooner; moreover, the cost is usually covered by Medicare or Medicaid.

With hospice, death assumes a more natural trajectory, unencumbered by frightening machines and sometimes grotesque interventions of modern medicine that do little, if anything, to prolong life and often make dying more painful for patients and families, as well as costlier for society.

Indeed, studies have shown that, all other things being equal, patients receiving the comfort care provided by hospice tend to live longer and die more peacefully than those who continue to get intensive care for their disease when treatment has ceased to help.