Experience with a Hospice-care Program for the Terminally Ill J. M. ZIMMERMAN, M.D. A hospice-care program offers an opportunity to provide effective palliative care for patients terminally ill with malignant disease and to develop improved methods for coping with the problems of the dying patient. All patients for whom antitumor therapy does not offer a reasonable possibility of cure are eligible for Church Hospital's multidisciplinary program, the focus of which is on both the patient and his family. Acceptance by medical staff, patients and families has been enthusiastic. Both conventional and unconventional methods can be helpful in making terminally ill patients more comfortable. Much has been learned about the control of pain in such patients. Intestinal obstruction can often be managed non-operatively without the use of nasogastric tube. Other common symptoms such as weakness, anorexia, depression, dyspnea, etc. can be relieved with varying degrees of success. An objective of the program is to allow the patient to be at home for most of his terminal illness and to die there if possible. By utilizing patient and family instruction, visiting nurses and home health aides, approximately two-thirds of the patients in the program at any given time are at home. Basing the program in an acute care hospital has allowed coordination with the curative treatment of malignant disease and effective use of radiation and chemotherapy for palliative purposes. The organizational structure, financing, facilities and clinical experience with 100 consecutive patients of the Church Hospital hospice-care program are described. ESPITE IMPROVEMENT in the management of
cancer, there are many patients for whom cure cannot be achieved. Palliative care which will provide
maximum quality and duration of life for such patients presents a challenge.3'9 Current conventional treatment is not optimal, as there is a tendency at one extreme to provide minimal care and attention because "nothing further can be done" and at the other extreme to utilize multiple modalities of antitumor therapy in a frantic effort to "do something."8 The medical, psychological and social reasons for these approaches are various. The author's experience suggests that the Presented at the Annual Meeting of the Southern Surgical Association, December 4-6 1978, Hot Springs, Virginia. Reprint requests: J. M. Zimmerman, M.D., Church Home and Hospital, 100 North Broadway, Baltimore, Maryland 21231. Submitted for publication: December 7, 1978.
From the Surgical Service, Church Hospital, Baltimore, Maryland
hospice-care approach5'11 offers an opportunity to improve the treatment of the dying patient. The hospice concept has in recent years developed in England. The work of Saunders10 at St. Joseph's Hospice in London led her to open St. Christopher's Hospice in Sydenham in 1967. There a broad-based approach to the care of the terminally ill was developed with particular attention to the control of pain. As the movement grew in England13 the concept was brought to North America by physicians trained at St. Christopher's. Notable among these are Mount7 at Royal Victoria Hospital in Montreal and Lack6 at Hospice Incorporated in Connecticut. Many hospices are now in various stages of development throughout the United States. Within the last 5 years a hospice-care program has been initiated at Church Hospital and has gradually grown. The idea was germinated by the hospital chaplain, Rev. Paul Dawson, who gained the interest of key members of the medical and hospital staff from various departments. After study, this group became convinced that a hospice program at the hospital would meet a need and was feasible. The matter was very carefully presented to the medical staff, the hospital management and board of directors to obtain their concurrence. Visits were then made to several hospices in England, to the Royal Victoria Hospital and to Hospice Incorporated. A program suited to Church Hospital was designed and approved by medical staff, hospital management and directors. The program was begun gradually by incorporating various features of hospice-care such as measures for pain control and emotional support. Only later was the decision made to place all hospice inpatients on one floor, and even today there is no designated hospice area on this floor. Our hospice therefore is a program not a place. As it must be, by the nature of the undertaking, it is a developing program.
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General Considerations The objectives of a hospice-care program are to provide improved patient care, education and research in the field of terminal illness. In many of the British hospices, though the primary effort is directed at patients with malignant disease, a variety of other disorders such as progressive neurological disease are included. For tactical purposes our program has been directed only at cancer patients for whom curative treatment is unlikely to be successful. In medieval times a hospice was a way station for travellers. Though the term admittedly lacks clarity, we have adopted it because its use has already become widely accepted and there does not appear to be an alternative which is both simple and accurate. Cardinal Principles of Hospice-Care A key feature of hospice-care is that it is directed primarily at symptom control rather than at tumor control. This does not mean that all antitumor therapy is out of place in such a program, but simply that it plays a secondary role in that it is employed only as it contributes to symptom control. In speaking of the terminally ill with cancer, the phrase "nothing more can be done" is sometimes used. A basic contention of the hospice-care program is that very much can be done to relieve symptoms and to provide comfort. A hospice-care program is multidisciplinary. Physicians, nurses, clinical nurse practitioners, social workers, physical therapists, chaplains and volunteers all are important components of our program. Symptoms can come from a variety of sources: physical, psychological, social, financial, etc., and a team app1roach is best suited to this situation. Patients are highly individual in their ability to relate to various members of the team, and it is not uncommon for the most important support to come from a nonphysician member of the team. It must be remembered that terminally ill patients bring with them all of the baggage of life, including pre-existing personality, marital and
financial problems. In a hospice-care program the unit of care is not the patient but the patient and his family. Not only is the family subject to the stresses of the patient's terminal illness, but also it can become, if properly handled, a vital instrument in the care of the patient. Hospice-care is both an inpatient and outpatient program. With the cooperation of family and the availability of home care staff, including visiting nurses, home health aides, physical therapists, social workers and volunteers, much of terminal care can be pro-
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vided at home. Frequently it is possible for the patient to die at home, which is the preference of many patients and their families. The Church Hospital Hospice-Care Program: Organization and Clinical Experience
The Church Hospital hospice-care program is, of course, hospital based, as distinct from most of the English hospices. It is under the direction of a medical staff committee which establishes policy and oversees the program. A part-time hospice medical director, whose background is in family practice, is in charge of the program. A physician who has a patient whom he feels might profit from hospice-care refers the patient to the hospice medical director, who makes the decision regarding acceptance of the patient into the program, occasionally with consultation from the Hospice-Care Committee. An important feature of our program is the referring physician's option to determine the extent of his continuing involvement in the patient's care. He may transfer the patient to the hospice medical director or continue as the patient's attending physician, with consultation as needed from the hospice-care director. The referring physician provides to the hospice-care staff the pertinent information, on printed forms, regarding the patient's history. Once the patient enters the program, all of its facilities, including home care, are available to the patient and his family. If the patient is hospitalized, he is placed in a bed on the nursing unit which houses hospicecare patients. In addition to the hospice medical director, the staff for the program consists of nursing and other personnel assigned to the nursing unit and two visiting nurses. Staff members, except for nurses, handle both inpatients and outpatients. All personnel have some nonhospice-related responsibilities, but all, including volunteers, receive special training in the care of the terminally ill and participate in continuing education programs on hospice-care. The 100 patients admitted to the program during the first ten months of 1978 constitute a representative sample of our hospice patients. In this group there have been 48 males and 52 females. They range in age from 14 to 85; approximately two-thirds have been in the seventh and eighth decades of life. The most common primary tumors have been those of lung, pancreas and colon, with somewhat fewer in the breast, rectum and esophagus. A number of other primary sites are represented, and naturally in a few of the patients the source of the primary tumor is unknown.
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Ninety-five of the 100 patients have had at least a portion of their terminal care in the hospital. Among the 82 patients who entered the program while in the hospital, it has been possible to discharge 42 to their homes for a portion of their terminal illness. As of November 17, 1978, 70 of the 100 patients had died, 20 of these having passed away at home. However, among those having a portion of their care at home, more than half died at home. Length of hospital stay has ranged from I to 33 days, with an average of just under 10 days hospitalization. This compares with a range of 1 to 300+ days and a mean duration of approximately 26 days in the hospice program. Figures for length of stay are, of course, difficult to analyze because of the wide range. In any event, on a given day approximately two-thirds of all the patients in the program are outpatients. In the vast majority of the 100 patients the referring physician has requested the hospice medical director to become the patient's attending physician while in the program. For control of pain Brompton's mixture has been used in 58 of the patients. With respect to symptom control we have generally been quite pleased with our success in relief of pain. Comments from patients and relatives indicate that the psychological and emotional support has been most helpful to them. In general, relief of symptoms of weakness and anorexia has been less satisfactory. Naturally the least satisfactory overall benefit was achieved in those patients who died soon after entry into the program. In retrospect, some of these patients could have been identified prior to their acceptance, and it is our conviction that patients with very limited life expectancy at the time of referral should be excluded. It is hoped that as familiarity with the program increases, patients will be referred to it earlier in the course of their illness. Symptom Relief Relief of symptoms in terminally ill cancer patients often involves simply the application of conventional therapeutic measures, but it occasionally includes the use of unconventional techniques. Although much is now known about the relief of symptoms in terminal illness, much remains to be learned. Pain Many but not all patients with terminal malignant disease have pain. For those who do, pain must be controlled before other symptoms can be handled ef-
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fectively. This is an area in which hospice programs have contributed substantially to our knowledge. Almost all patients with advanced malignancy fear both uncontrollable pain and the possibility of being so "doped up" in the effort to relieve the pain that they are rendered subhuman. Through the work at St. Christopher's and elsewhere we have learned that by using various modalities it is possible to keep most patients pain-free and alert throughout much of their terminal illness. The first step in pain control is to determine the cause of pain. It must be remembered that patients with advanced tumors can have symptoms originating from other sources, such as dental caries, constipation, hemorrhoids, etc.; appropriate pain-relieving measures must be taken to deal with these problems. If pain is due to tumor, first consideration should be given to the possibility that antitumor therapy (excision, radiation therapy or chemotherapy) might be helpful; otherwise, other measures must be undertaken. For tumor pain not amenable to antitumor therapy many modalities are available: nerve block, neurosurgical procedures, electrical stimulation, hypnosis and pharmacological agents. Though other methods are employed in some instances, we have found that, in general, pharmacological techniques have resulted in maximum control of pain with minimum side effect. As in all pain relief by pharmacological measures, the mildest agent capable of producing relief should be employed. For some patients aspirin or acetaminophen prove quite satisfactory, while for others morphine and morphine derivatives are essential. Two important points to remember in the alleviation of pain from advanced malignancy are that it is easier to prevent than to relieve intense pain and that fear of additional pain is an important symptom in the terminally ill. For these reasons the use of analgesics on ap.r.n. basis, which is quite suitable in the management of acute pain, plays little role in the management of chronic pain. Analgesic medication must be given on a regular basis. Furthermore, assurance that pain can be relieved without producing mental obtundation is an important element in the patient's care. Relief from chronic pain can be seen as a spectrum, with uncontrolled pain at one extreme and unconsciousness at the opposite; in the center there is, with many drugs, an area within which chronic pain is relieved and the patient is alert. The aim of treatment is to "titrate" the dosage regimen so that the patient is in this portion of the spectrum. Although a variety of analgesic drugs can be used for this purpose if given regularly and with appropriate dosage adjustment, a modified Brompton's mixture
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686 TABLE 1. Modified Brompton's Mixture
Morphine Cocaine Aromatic elixir Water
5 mgT 10 mg 10 ml 10 ml
(Table 1) has been found to be particularly effective, and we have used it regularly. It is a combination of morphine in variable dosage, cocaine, alcohol, syrup and water. The original Brompton's mixture is an old prescription, presumably originating at the Brompton's Chest Hospital, containing heroin"2 in place of morphine and also some chloroform water. Heroin is still used in Brompton's mixture at many English hospices. Treatment with Brompton's mixture is initiated at 20 cc every 4 hours, usually with a relatively low dosage of morphine. Without changing the volume of each dose, the morphine can be adjusted as needed to bring the patient into that central portion of the pain relief spectrum, in which he is pain free and mentally alert. Initially the patient is also given Compazine® syrup 5 mg. every 4 hours for its tranquilizing and antiemetic effects. Its dosage and timing can also be adjusted as necessary. Once stability in dosage and timing of Brompton's mixture and Compazine syrup is achieved, the two medications can be combined. It is our conviction that the pattern of administration on a regular basis rather than the pharmacology of Brompton's mixture is the essential element in the success we have had in pain relief. Like other hospice groups we are prepared to test single agents, such as oral morphine or methadone, in place of Brompton's mixture.4 In bone pain due to osseous metastases the addition of an antiinflammatory agent, such as phenylbutazone or indomethacin, is sometimes helpful. Insofar as possible, analgesic medications are given orally in liquid form. In the patient with intractable vomiting or dysphagia so severe as to prevent swallowing even small quantities of liquids, Dilaudid® suppositories are often effective; if not, parenteral therapy, usually with morphine plus Compazine, must be used. It cannot be emphasized too strongly that psychological and social problems can aggravate physical pain. Support in coping with such problems can simplify the management of chronic pain. Weakness
Weakness is a common symptom in patients with advanced malignancy. Again the first step is to look for specific causes, such as anemia, hypokalemia and
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hypercalcemia, and to treat these appropriately. Encouragement in activity and formal physical therapy can be helpful in combating weakness. When such measures fail and weakness is a predominant symptom, the use of prednisone or a testosterone preparation may be helpful. Anorexia
Loss ofappetite and unwillingness to eat are common occurrences in the terminally ill. Such anorexia is often more distressing to the family than to the patient; as a consequence they exhort the patient to eat and present him with large quantities of nutritious food, which often aggravates the anorexia. This is an area in which understanding on the part of the family can be most helpful. They must learn that emphasis should now shift from maintenance of nutritional status and amount of food to enhancing the patient's comfort through the provision of small appetizing meals. Success in making this transition usually results in considerable relief to the patient and his family. For the hospitalized patient discussion of meal planning with the dietitian can be very helpful. Prednisone will, for some patients, produce improvement in appetite. Thirst The combination of morphine, dehydration and mouth breathing often results in some combination of troublesome thirst and dry mouth. For this, careful attention to mouth care and the provision of frequent small sips of fluid can provide remarkable relief.
Constipation The combination of inactivity, decreased dietary fiber and the use of narcotics set the stage for constipation in many patients. The use of Colaceg in dosages of 200-600 mg/day plus Senokot® two to six tablets per day generally keeps patients free of this distressing symptom. If fecal impaction occurs, it must be dealt with in the conventional fashion. Depression In handling the depression which is so common in dying patients the provision of simple psychological support by members of the hospice-care team can often be extremely effective. This, combined with relief of pain and easing of some of the social and financial burdens, can improve the patient's mood. The use of Elavil® is frequently beneficial. Only in unusual circumstances is psychiatric consultation employed.
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Dyspnea
Those causes of dyspnea which can be treated by specific therapeutic measures should be dealt with appropriately; pleural fluid accumulation should be drained, bronchospasm should be relieved with the use of bronchodilators and congestive heart failure should be treated in the conventional fashion. To the extent that such measures do not produce relief, the provision of ample reassurance, careful positioning of the patient, the use of oxygen and the administration of sedatives and narcotics can provide sufficient palliation in many instances. Cough Treatable causes of troublesome cough should be handled in conventional fashion. Postnasal drip should be managed in the usual way, and, except for in the patient with very advanced tumor, pneumonia should be treated with appropriate antibiotics. When the cause of bothersome cough cannot be treated, expectorants should be employed to thin tenacious sputum and codeine-containing preparations should be used to diminish the cough reflex. Ascites In symptomatic ascites aggressive conventional therapy, including diuretics and paracentesis, can produce considerable palliative effect. Dysphagia For most patients with severe dysphagia and very advanced tumors adequate hydration and nutrition can be maintained by patiently giving small frequent feedings of liquids. For the patient with a less advanced tumor more aggressive measures, such as the passage of a feeding tube or the insertion of an intraluminal esophageal tube (e.g., Celesting), may be warranted. The use of gastrostomy or intravenous fluids is seldom called for in patients with advanced malignancy, although these measures may be helpful in a limited number of patients. In handling dysphagia there is need for individualization of treatment, based upon a careful assessment of the particular situation. Intestinal Obstruction Planning suitable treatment for intestinal obstruction in the terminally ill also requires individualization. The level and degree of obstruction, the extent of the tumor and the general condition of the patient all are factors which determine selection of appropriate
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therapy. For example, when complete distal colonic obstruction occurs in a patient with relatively limited, although incurable, tumor, the performance of colostomy can provide excellent palliation. On the other hand, from time to time we see patients with partial small bowel obstruction from widely disseminated intraperitoneal tumor. Many of these patients can be kept quite comfortable by non-operative means without the use of a nasogastric tube. Pain can be controlled as described previously. Of interest is the fact that nausea is generally a much more bothersome symptom to the patient than is vomiting; therefore, without the use of nasogastric tube and intravenous fluids, the patient can be given large doses of antiemetics and stool softeners and be allowed to eat and drink. Under these circumstances he will be largely free of pain and nausea but will vomit periodically while remaining surprisingly comfortable. Though not an ideal situation, this method allows the patient a more comfortable demise than the performance of a futile laparotomy at which the peritoneal cavity may be found to be seeded with extensive tumor-producing multiple points of obstruction.2
Fungating Growths Critical to the proper management of the terminally ill patient with a seminecrotic fungating growth on the body surface is intensive local care to the growth to keep it clean and odorless. Dysgeusia An altered sense of taste is a symptom which occurs occasionally in patients with advanced malignancy, as well as in certain other disorders. We have seen a few patients whose only symptom has been a bad taste in their mouths, which they have found extremely annoying. The use of zinc sulfate by mouth has been recommended, but controlled trial has not supported its usefulness. Our results with the administration of zinc sulfate for dysgeusia have been variable. This is one of a number of symptoms which warrant further investigation of palliative care as it can be most distressing to the few patients who experience it. Many other symptoms which are relatively common in the terminally ill, such as diarrhea and pruritus, have been seen in our patients and have been treated with varying degrees of success. For some of these, much needs to be learned about effective palliative care if treatment of the terminally ill is to achieve optimum success. The key to symptom control is adequate communication with the patient regarding his symptoms.- One
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cannot treat symptoms effectively unless one takes care to elicit information about their presence and nature. This requires both time and a proper attitude on the part of those caring for the patient. Once symptoms are recognized, treatment must be tailored to the symptoms and to the overall situation of the patient. Careful follow-up, with adjustment of therapy as needed, is essential to success.
The Family The aim of the hospice-care team in dealing with the patient's family is, on the one hand, to develop the family's understanding and insight and, on the other, to provide them with support. They need to comprehend, to the extent possible, the nature of the patient's illness and the aims of palliative care. Aside from the comfort which such understanding gives, it enables the family to make important contributions to the patient's treatment. Providing support to the family involves both practical measures, such as assistance with financial problems through community resources, and the rendering of such emotional assistance as may be necessary. Hospice-care does not end with the death of the patient; bereavement follow-up for the family can be of immense value in their coping with both the grief and some of the practical crises which occur after the death of a family member.
Inpatient-Outpatient Features
By utilizing the above measures for symptom control it is possible to keep many of the patients at home during a large portion oftheir terminal illness. As noted, at any given time approximately two-thirds of our patients are at home, and approximately 30% have died at home. For home care to function effectively, visits by members of the hospice-care staff are essential. The number and timing of the visits are scheduled to meet the particular needs of the patient and the family. Coordination of inpatient and outpatient care is maintained through the patient's attending physician (who may be either the patient's original primary physician or the hospice-care director, as noted above) and through other members of the hospice-care staff who participate in both inpatient and outpatient aspects of his management. Although the visiting nurses are distinct from the inpatient nursing personnel, excellent cooperation between these groups avoids fragmentation of the patient's care. In the vast majority of instances the patient and his family prefer that the patient be at home as much of the time as possible. Obviously there are also financial
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advantages to minimizing inpatient care. The amount of time which can be spent at home during the terminal illness clearly depends on the individual circumstances of each case. In addition to simple means of symptom control and adequate staffing, there are two other requirements for effective home care: adequate equipment for the patient's particular needs and the readyavailability of hospitalization when it is required. Financial Aspects Except perhaps for some "start-up" expenses, a hospice-care program should be self-supporting financially. Sources of reimbursement for inpatients are essentially the same as those for conventional terminal care. Many third party payers recognize the value of home care as an alternative to hospitalization, so that once appropriate approval is obtained for a home-care program, expenses for insured patients are covered to varying degrees, depending upon plan coverage. Unfortunately, many insurance purchasers do not yet see the virtues of home-care coverage. There remain, therefore, some unresolved problems in financing, but these should not prove insurmountable. Among those who have observed the function of the Church Hospital Hospice-Care Program there is no doubt that it is "care effective." In the current atmosphere one must also ask whether it is "cost effective. "9 There are many facets of this question which are beyond the scope of this paper. Suffice it to say that it is our conviction that a hospice-care program is economically efficient. Inpatient care in the program is admittedly intensive. Although it is a realtively low level of care technologically, with far fewer diagnostic and therapeutic maneuvers, it does require a high level of personal attention. Nonetheless, it would appear that the average daily cost for a hospice-care inpatient is approximately 80% of that for the average intermediate care patient in our hospital. In addition, it appears that a far greater amount of time during the terminal illness is spent as an outpatient by hospicecare patients than by those terminal patients managed in traditional fashion. When somewhat Jwer daily inpatient costs with shorter hospital stays are combined with somewhat higher outpatient costs, it is our impression that, assuming comparable length of terminal illness, hospice-care offers an economically attractive alternative to traditional terminal care. In assessing relative costs the base of comparison is important. If hospice-care is compared with conscientious conventional treatment for the terminally ill, including prolonged hospitalization, numerous
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diagnostic tests and the liberal use of radiation and chemotherapy, hospice-care is almost certainly more economical. On the other hand, if it is compared with virtually no care at all, it is clearly more expensive.
S. W.: Survival After Palliative Surgery for Advanced Intraabdominal Cancer. Am. J. Surg., 134:575, 1977. 3. Dunphy, J. E.: On Caring for the Patient with Cancer. N. EngI. J. Med., 295:313, 1976. 4. Eastman, M.: Shattering Myths About Hospice Care. Am. Pharm., 18:20, 1978. 5. Krant, M. J.: The Hospice Movement. N. Engl. J. Med., 299:
Conclusion There is still much to be learned about both the relief of symptoms and the optimal means of organizing programs of care for the dying patient. Experience with the hospice-care program at Church Hospital indicates that it has provided improved care for the terminally ill and their families at a reasonable cost.
546, 1978. 6. Lack, S. A. and Buckingham, R. W., III: First American Hospice. New Haven, Conn., Hospice Inc., 1978. 7. Mount, B. M.: The Problem of Caring for the Dying in a General Hospital: Can. Med. Assoc. J., 115:119, 1976. 8. Mount, B. M., Jones, A. and Patterson, A.: Death and Dying: Attitudes in a General Hospital. Urology, 4:741, 1974. 9. Ryder, C. F. and Ross, D. M.: Terminal Care-Issues and Alternatives. Public Health Rep., 92:20, 1977. 10. Saunders, C.: Hospice Care. Am. J. Med., 65:726, 1978. 11. Stoddard, S.: The Hospice Movement. Briarcliff, N.Y., Stein and Day, 1978. 12. Twycross, R.: Clinical Experience with Diamorphine in Advanced Malignant Disease. Int. J. Clin. Pharmacol., 9:189, 1974. 13. Wilkes, S.: Some Problems in Caner Management. Proc. R. Soc. Med., 67:23, 1974.
References 1. Brewin, T. B.: The Cancer Patient: Communication and Morale. Br. Med. J., 2:1623, 1977. 2. Brown, P. W., Terz, J. J., Lawrence, W. and Blievenicht,
DISCUSSION DR. GEORGE G. FINNEY (Stevenson, Maryland): When I read the paper, there were three things that struck me which I thought were very worthwhile. First, the team aspect: After all, in the operating room there is the operator, yes, but there are the assistants, the nurses, and others who enter in in such an important way that things could not do well without them; and in this way, with the different ones that can be called on for help, it's bound to be an asset of great value to the overall treatment of the patient. The second thing that impressed me very much was the fact that hospital and home are both utilized. The home part can make such a difference in so many individuals in the latter stages of life, and not only their well-being, but also in really getting along in a worthwhile way. The home also, of course, brings in the family, so that they have a chance to understand in a much better way the problems that the doctors face. Finally, the third thing that impressed me is that I can't help but believe that not only the physical but the psychological part of the patient can be handled so much better. In these days, you know, when there is some publicity that doctors are not thought of as well as they would like to think they could be, a lot has to do with the word that Dr. Zimmerman used- "communication" -and that is certainly one of the most important aspects. If through this team treatment the physical and the psychological side ofthe patient can be handled well, things are bound to go along as well as possible. I certainly am not a very good prognosticator, but I can't help but believe that there will be more units of this kind over the country, to the benefit of patients. DR. THOMAS N. P. JOHNS (Richmond, Virginia): Last May in Washington Senator Howard Baker of Tennessee presented the first Jack C. Massey Award of $50,000 to two individuals for their outstanding contributions to health care. One of these recipients was the Reverend Carlton J. Sweetser, a hospital chaplain and director of the hospice at St. Luke's, in New York. The opportunity to know this man and to hear the details of his program convinced
one who was a skeptic of the hospice idea that this, indeed, fills a void in which many find themselves at life's end. The hospital-based hospice program, as exemplified at Church Hospital and presented by Dr. Zimmerman, emphasizes that this is a "people caring for people" program. That is where the emphasis should be. Unfortunately, as Dr. Zimmerman indicates, the word "hospice" suggests a place, and for the past several months health planners have picked up hospice as a so-called cost saving alternative to hospital care. We are now facing-and this is true of the coming General Assembly in Virginia next month-the prospect of legislation being introduced to license free-standing hospices and bring them under certificate of need regulation, thereby making them another toy for the games health service agencies play. The suggestion that such free-standing places will help contain cost is patently ridiculous, and not only will capital and operating expenses in the face of uncertain future usage (I say "uncertain" because of suspected improvements in cancer control) but another layer of bureaucratic support and regulatory control will result, at predictably incalculable cost. But the hospice program, as described by Dr. Zimmerman, and based in hospitals, is really a need, I believe, and should be given a significant place in health planning. These programs, as Dr. Finney has said, should have our support in our communities, and at the same time, I think, we should oppose the proliferation of freestanding institutions for the terminally ill. That Dr. Zimmerman addressed himself to cost is a significant feature of his paper. It should be that surgeons participate as best we can in caring for those whose infirmities are no longer under human control, and this, I think, can best be done in programs such as described by Dr. Zimmerman.
DR. J. SHELTON HORSLEY, III (Richmond, Virginia): I appreciate having the opportunity to review Dr. Zimmerman's manuscript before he gave his excellent presentation this afternoon. At the Medical College of Virginia/Virginia Commonwealth University Cancer Center we are very interested in the hospice program. I
cancer, there are many patients for whom cure cannot be achieved. Palliative care which will provide
maximum quality and duration of life for such patients presents a challenge.3'9 Current conventional treatment is not optimal, as there is a tendency at one extreme to provide minimal care and attention because "nothing further can be done" and at the other extreme to utilize multiple modalities of antitumor therapy in a frantic effort to "do something."8 The medical, psychological and social reasons for these approaches are various. The author's experience suggests that the Presented at the Annual Meeting of the Southern Surgical Association, December 4-6 1978, Hot Springs, Virginia. Reprint requests: J. M. Zimmerman, M.D., Church Home and Hospital, 100 North Broadway, Baltimore, Maryland 21231. Submitted for publication: December 7, 1978.
From the Surgical Service, Church Hospital, Baltimore, Maryland
hospice-care approach5'11 offers an opportunity to improve the treatment of the dying patient. The hospice concept has in recent years developed in England. The work of Saunders10 at St. Joseph's Hospice in London led her to open St. Christopher's Hospice in Sydenham in 1967. There a broad-based approach to the care of the terminally ill was developed with particular attention to the control of pain. As the movement grew in England13 the concept was brought to North America by physicians trained at St. Christopher's. Notable among these are Mount7 at Royal Victoria Hospital in Montreal and Lack6 at Hospice Incorporated in Connecticut. Many hospices are now in various stages of development throughout the United States. Within the last 5 years a hospice-care program has been initiated at Church Hospital and has gradually grown. The idea was germinated by the hospital chaplain, Rev. Paul Dawson, who gained the interest of key members of the medical and hospital staff from various departments. After study, this group became convinced that a hospice program at the hospital would meet a need and was feasible. The matter was very carefully presented to the medical staff, the hospital management and board of directors to obtain their concurrence. Visits were then made to several hospices in England, to the Royal Victoria Hospital and to Hospice Incorporated. A program suited to Church Hospital was designed and approved by medical staff, hospital management and directors. The program was begun gradually by incorporating various features of hospice-care such as measures for pain control and emotional support. Only later was the decision made to place all hospice inpatients on one floor, and even today there is no designated hospice area on this floor. Our hospice therefore is a program not a place. As it must be, by the nature of the undertaking, it is a developing program.
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General Considerations The objectives of a hospice-care program are to provide improved patient care, education and research in the field of terminal illness. In many of the British hospices, though the primary effort is directed at patients with malignant disease, a variety of other disorders such as progressive neurological disease are included. For tactical purposes our program has been directed only at cancer patients for whom curative treatment is unlikely to be successful. In medieval times a hospice was a way station for travellers. Though the term admittedly lacks clarity, we have adopted it because its use has already become widely accepted and there does not appear to be an alternative which is both simple and accurate. Cardinal Principles of Hospice-Care A key feature of hospice-care is that it is directed primarily at symptom control rather than at tumor control. This does not mean that all antitumor therapy is out of place in such a program, but simply that it plays a secondary role in that it is employed only as it contributes to symptom control. In speaking of the terminally ill with cancer, the phrase "nothing more can be done" is sometimes used. A basic contention of the hospice-care program is that very much can be done to relieve symptoms and to provide comfort. A hospice-care program is multidisciplinary. Physicians, nurses, clinical nurse practitioners, social workers, physical therapists, chaplains and volunteers all are important components of our program. Symptoms can come from a variety of sources: physical, psychological, social, financial, etc., and a team app1roach is best suited to this situation. Patients are highly individual in their ability to relate to various members of the team, and it is not uncommon for the most important support to come from a nonphysician member of the team. It must be remembered that terminally ill patients bring with them all of the baggage of life, including pre-existing personality, marital and
financial problems. In a hospice-care program the unit of care is not the patient but the patient and his family. Not only is the family subject to the stresses of the patient's terminal illness, but also it can become, if properly handled, a vital instrument in the care of the patient. Hospice-care is both an inpatient and outpatient program. With the cooperation of family and the availability of home care staff, including visiting nurses, home health aides, physical therapists, social workers and volunteers, much of terminal care can be pro-
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vided at home. Frequently it is possible for the patient to die at home, which is the preference of many patients and their families. The Church Hospital Hospice-Care Program: Organization and Clinical Experience
The Church Hospital hospice-care program is, of course, hospital based, as distinct from most of the English hospices. It is under the direction of a medical staff committee which establishes policy and oversees the program. A part-time hospice medical director, whose background is in family practice, is in charge of the program. A physician who has a patient whom he feels might profit from hospice-care refers the patient to the hospice medical director, who makes the decision regarding acceptance of the patient into the program, occasionally with consultation from the Hospice-Care Committee. An important feature of our program is the referring physician's option to determine the extent of his continuing involvement in the patient's care. He may transfer the patient to the hospice medical director or continue as the patient's attending physician, with consultation as needed from the hospice-care director. The referring physician provides to the hospice-care staff the pertinent information, on printed forms, regarding the patient's history. Once the patient enters the program, all of its facilities, including home care, are available to the patient and his family. If the patient is hospitalized, he is placed in a bed on the nursing unit which houses hospicecare patients. In addition to the hospice medical director, the staff for the program consists of nursing and other personnel assigned to the nursing unit and two visiting nurses. Staff members, except for nurses, handle both inpatients and outpatients. All personnel have some nonhospice-related responsibilities, but all, including volunteers, receive special training in the care of the terminally ill and participate in continuing education programs on hospice-care. The 100 patients admitted to the program during the first ten months of 1978 constitute a representative sample of our hospice patients. In this group there have been 48 males and 52 females. They range in age from 14 to 85; approximately two-thirds have been in the seventh and eighth decades of life. The most common primary tumors have been those of lung, pancreas and colon, with somewhat fewer in the breast, rectum and esophagus. A number of other primary sites are represented, and naturally in a few of the patients the source of the primary tumor is unknown.
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Ninety-five of the 100 patients have had at least a portion of their terminal care in the hospital. Among the 82 patients who entered the program while in the hospital, it has been possible to discharge 42 to their homes for a portion of their terminal illness. As of November 17, 1978, 70 of the 100 patients had died, 20 of these having passed away at home. However, among those having a portion of their care at home, more than half died at home. Length of hospital stay has ranged from I to 33 days, with an average of just under 10 days hospitalization. This compares with a range of 1 to 300+ days and a mean duration of approximately 26 days in the hospice program. Figures for length of stay are, of course, difficult to analyze because of the wide range. In any event, on a given day approximately two-thirds of all the patients in the program are outpatients. In the vast majority of the 100 patients the referring physician has requested the hospice medical director to become the patient's attending physician while in the program. For control of pain Brompton's mixture has been used in 58 of the patients. With respect to symptom control we have generally been quite pleased with our success in relief of pain. Comments from patients and relatives indicate that the psychological and emotional support has been most helpful to them. In general, relief of symptoms of weakness and anorexia has been less satisfactory. Naturally the least satisfactory overall benefit was achieved in those patients who died soon after entry into the program. In retrospect, some of these patients could have been identified prior to their acceptance, and it is our conviction that patients with very limited life expectancy at the time of referral should be excluded. It is hoped that as familiarity with the program increases, patients will be referred to it earlier in the course of their illness. Symptom Relief Relief of symptoms in terminally ill cancer patients often involves simply the application of conventional therapeutic measures, but it occasionally includes the use of unconventional techniques. Although much is now known about the relief of symptoms in terminal illness, much remains to be learned. Pain Many but not all patients with terminal malignant disease have pain. For those who do, pain must be controlled before other symptoms can be handled ef-
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fectively. This is an area in which hospice programs have contributed substantially to our knowledge. Almost all patients with advanced malignancy fear both uncontrollable pain and the possibility of being so "doped up" in the effort to relieve the pain that they are rendered subhuman. Through the work at St. Christopher's and elsewhere we have learned that by using various modalities it is possible to keep most patients pain-free and alert throughout much of their terminal illness. The first step in pain control is to determine the cause of pain. It must be remembered that patients with advanced tumors can have symptoms originating from other sources, such as dental caries, constipation, hemorrhoids, etc.; appropriate pain-relieving measures must be taken to deal with these problems. If pain is due to tumor, first consideration should be given to the possibility that antitumor therapy (excision, radiation therapy or chemotherapy) might be helpful; otherwise, other measures must be undertaken. For tumor pain not amenable to antitumor therapy many modalities are available: nerve block, neurosurgical procedures, electrical stimulation, hypnosis and pharmacological agents. Though other methods are employed in some instances, we have found that, in general, pharmacological techniques have resulted in maximum control of pain with minimum side effect. As in all pain relief by pharmacological measures, the mildest agent capable of producing relief should be employed. For some patients aspirin or acetaminophen prove quite satisfactory, while for others morphine and morphine derivatives are essential. Two important points to remember in the alleviation of pain from advanced malignancy are that it is easier to prevent than to relieve intense pain and that fear of additional pain is an important symptom in the terminally ill. For these reasons the use of analgesics on ap.r.n. basis, which is quite suitable in the management of acute pain, plays little role in the management of chronic pain. Analgesic medication must be given on a regular basis. Furthermore, assurance that pain can be relieved without producing mental obtundation is an important element in the patient's care. Relief from chronic pain can be seen as a spectrum, with uncontrolled pain at one extreme and unconsciousness at the opposite; in the center there is, with many drugs, an area within which chronic pain is relieved and the patient is alert. The aim of treatment is to "titrate" the dosage regimen so that the patient is in this portion of the spectrum. Although a variety of analgesic drugs can be used for this purpose if given regularly and with appropriate dosage adjustment, a modified Brompton's mixture
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686 TABLE 1. Modified Brompton's Mixture
Morphine Cocaine Aromatic elixir Water
5 mgT 10 mg 10 ml 10 ml
(Table 1) has been found to be particularly effective, and we have used it regularly. It is a combination of morphine in variable dosage, cocaine, alcohol, syrup and water. The original Brompton's mixture is an old prescription, presumably originating at the Brompton's Chest Hospital, containing heroin"2 in place of morphine and also some chloroform water. Heroin is still used in Brompton's mixture at many English hospices. Treatment with Brompton's mixture is initiated at 20 cc every 4 hours, usually with a relatively low dosage of morphine. Without changing the volume of each dose, the morphine can be adjusted as needed to bring the patient into that central portion of the pain relief spectrum, in which he is pain free and mentally alert. Initially the patient is also given Compazine® syrup 5 mg. every 4 hours for its tranquilizing and antiemetic effects. Its dosage and timing can also be adjusted as necessary. Once stability in dosage and timing of Brompton's mixture and Compazine syrup is achieved, the two medications can be combined. It is our conviction that the pattern of administration on a regular basis rather than the pharmacology of Brompton's mixture is the essential element in the success we have had in pain relief. Like other hospice groups we are prepared to test single agents, such as oral morphine or methadone, in place of Brompton's mixture.4 In bone pain due to osseous metastases the addition of an antiinflammatory agent, such as phenylbutazone or indomethacin, is sometimes helpful. Insofar as possible, analgesic medications are given orally in liquid form. In the patient with intractable vomiting or dysphagia so severe as to prevent swallowing even small quantities of liquids, Dilaudid® suppositories are often effective; if not, parenteral therapy, usually with morphine plus Compazine, must be used. It cannot be emphasized too strongly that psychological and social problems can aggravate physical pain. Support in coping with such problems can simplify the management of chronic pain. Weakness
Weakness is a common symptom in patients with advanced malignancy. Again the first step is to look for specific causes, such as anemia, hypokalemia and
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hypercalcemia, and to treat these appropriately. Encouragement in activity and formal physical therapy can be helpful in combating weakness. When such measures fail and weakness is a predominant symptom, the use of prednisone or a testosterone preparation may be helpful. Anorexia
Loss ofappetite and unwillingness to eat are common occurrences in the terminally ill. Such anorexia is often more distressing to the family than to the patient; as a consequence they exhort the patient to eat and present him with large quantities of nutritious food, which often aggravates the anorexia. This is an area in which understanding on the part of the family can be most helpful. They must learn that emphasis should now shift from maintenance of nutritional status and amount of food to enhancing the patient's comfort through the provision of small appetizing meals. Success in making this transition usually results in considerable relief to the patient and his family. For the hospitalized patient discussion of meal planning with the dietitian can be very helpful. Prednisone will, for some patients, produce improvement in appetite. Thirst The combination of morphine, dehydration and mouth breathing often results in some combination of troublesome thirst and dry mouth. For this, careful attention to mouth care and the provision of frequent small sips of fluid can provide remarkable relief.
Constipation The combination of inactivity, decreased dietary fiber and the use of narcotics set the stage for constipation in many patients. The use of Colaceg in dosages of 200-600 mg/day plus Senokot® two to six tablets per day generally keeps patients free of this distressing symptom. If fecal impaction occurs, it must be dealt with in the conventional fashion. Depression In handling the depression which is so common in dying patients the provision of simple psychological support by members of the hospice-care team can often be extremely effective. This, combined with relief of pain and easing of some of the social and financial burdens, can improve the patient's mood. The use of Elavil® is frequently beneficial. Only in unusual circumstances is psychiatric consultation employed.
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Dyspnea
Those causes of dyspnea which can be treated by specific therapeutic measures should be dealt with appropriately; pleural fluid accumulation should be drained, bronchospasm should be relieved with the use of bronchodilators and congestive heart failure should be treated in the conventional fashion. To the extent that such measures do not produce relief, the provision of ample reassurance, careful positioning of the patient, the use of oxygen and the administration of sedatives and narcotics can provide sufficient palliation in many instances. Cough Treatable causes of troublesome cough should be handled in conventional fashion. Postnasal drip should be managed in the usual way, and, except for in the patient with very advanced tumor, pneumonia should be treated with appropriate antibiotics. When the cause of bothersome cough cannot be treated, expectorants should be employed to thin tenacious sputum and codeine-containing preparations should be used to diminish the cough reflex. Ascites In symptomatic ascites aggressive conventional therapy, including diuretics and paracentesis, can produce considerable palliative effect. Dysphagia For most patients with severe dysphagia and very advanced tumors adequate hydration and nutrition can be maintained by patiently giving small frequent feedings of liquids. For the patient with a less advanced tumor more aggressive measures, such as the passage of a feeding tube or the insertion of an intraluminal esophageal tube (e.g., Celesting), may be warranted. The use of gastrostomy or intravenous fluids is seldom called for in patients with advanced malignancy, although these measures may be helpful in a limited number of patients. In handling dysphagia there is need for individualization of treatment, based upon a careful assessment of the particular situation. Intestinal Obstruction Planning suitable treatment for intestinal obstruction in the terminally ill also requires individualization. The level and degree of obstruction, the extent of the tumor and the general condition of the patient all are factors which determine selection of appropriate
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therapy. For example, when complete distal colonic obstruction occurs in a patient with relatively limited, although incurable, tumor, the performance of colostomy can provide excellent palliation. On the other hand, from time to time we see patients with partial small bowel obstruction from widely disseminated intraperitoneal tumor. Many of these patients can be kept quite comfortable by non-operative means without the use of a nasogastric tube. Pain can be controlled as described previously. Of interest is the fact that nausea is generally a much more bothersome symptom to the patient than is vomiting; therefore, without the use of nasogastric tube and intravenous fluids, the patient can be given large doses of antiemetics and stool softeners and be allowed to eat and drink. Under these circumstances he will be largely free of pain and nausea but will vomit periodically while remaining surprisingly comfortable. Though not an ideal situation, this method allows the patient a more comfortable demise than the performance of a futile laparotomy at which the peritoneal cavity may be found to be seeded with extensive tumor-producing multiple points of obstruction.2
Fungating Growths Critical to the proper management of the terminally ill patient with a seminecrotic fungating growth on the body surface is intensive local care to the growth to keep it clean and odorless. Dysgeusia An altered sense of taste is a symptom which occurs occasionally in patients with advanced malignancy, as well as in certain other disorders. We have seen a few patients whose only symptom has been a bad taste in their mouths, which they have found extremely annoying. The use of zinc sulfate by mouth has been recommended, but controlled trial has not supported its usefulness. Our results with the administration of zinc sulfate for dysgeusia have been variable. This is one of a number of symptoms which warrant further investigation of palliative care as it can be most distressing to the few patients who experience it. Many other symptoms which are relatively common in the terminally ill, such as diarrhea and pruritus, have been seen in our patients and have been treated with varying degrees of success. For some of these, much needs to be learned about effective palliative care if treatment of the terminally ill is to achieve optimum success. The key to symptom control is adequate communication with the patient regarding his symptoms.- One
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cannot treat symptoms effectively unless one takes care to elicit information about their presence and nature. This requires both time and a proper attitude on the part of those caring for the patient. Once symptoms are recognized, treatment must be tailored to the symptoms and to the overall situation of the patient. Careful follow-up, with adjustment of therapy as needed, is essential to success.
The Family The aim of the hospice-care team in dealing with the patient's family is, on the one hand, to develop the family's understanding and insight and, on the other, to provide them with support. They need to comprehend, to the extent possible, the nature of the patient's illness and the aims of palliative care. Aside from the comfort which such understanding gives, it enables the family to make important contributions to the patient's treatment. Providing support to the family involves both practical measures, such as assistance with financial problems through community resources, and the rendering of such emotional assistance as may be necessary. Hospice-care does not end with the death of the patient; bereavement follow-up for the family can be of immense value in their coping with both the grief and some of the practical crises which occur after the death of a family member.
Inpatient-Outpatient Features
By utilizing the above measures for symptom control it is possible to keep many of the patients at home during a large portion oftheir terminal illness. As noted, at any given time approximately two-thirds of our patients are at home, and approximately 30% have died at home. For home care to function effectively, visits by members of the hospice-care staff are essential. The number and timing of the visits are scheduled to meet the particular needs of the patient and the family. Coordination of inpatient and outpatient care is maintained through the patient's attending physician (who may be either the patient's original primary physician or the hospice-care director, as noted above) and through other members of the hospice-care staff who participate in both inpatient and outpatient aspects of his management. Although the visiting nurses are distinct from the inpatient nursing personnel, excellent cooperation between these groups avoids fragmentation of the patient's care. In the vast majority of instances the patient and his family prefer that the patient be at home as much of the time as possible. Obviously there are also financial
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advantages to minimizing inpatient care. The amount of time which can be spent at home during the terminal illness clearly depends on the individual circumstances of each case. In addition to simple means of symptom control and adequate staffing, there are two other requirements for effective home care: adequate equipment for the patient's particular needs and the readyavailability of hospitalization when it is required. Financial Aspects Except perhaps for some "start-up" expenses, a hospice-care program should be self-supporting financially. Sources of reimbursement for inpatients are essentially the same as those for conventional terminal care. Many third party payers recognize the value of home care as an alternative to hospitalization, so that once appropriate approval is obtained for a home-care program, expenses for insured patients are covered to varying degrees, depending upon plan coverage. Unfortunately, many insurance purchasers do not yet see the virtues of home-care coverage. There remain, therefore, some unresolved problems in financing, but these should not prove insurmountable. Among those who have observed the function of the Church Hospital Hospice-Care Program there is no doubt that it is "care effective." In the current atmosphere one must also ask whether it is "cost effective. "9 There are many facets of this question which are beyond the scope of this paper. Suffice it to say that it is our conviction that a hospice-care program is economically efficient. Inpatient care in the program is admittedly intensive. Although it is a realtively low level of care technologically, with far fewer diagnostic and therapeutic maneuvers, it does require a high level of personal attention. Nonetheless, it would appear that the average daily cost for a hospice-care inpatient is approximately 80% of that for the average intermediate care patient in our hospital. In addition, it appears that a far greater amount of time during the terminal illness is spent as an outpatient by hospicecare patients than by those terminal patients managed in traditional fashion. When somewhat Jwer daily inpatient costs with shorter hospital stays are combined with somewhat higher outpatient costs, it is our impression that, assuming comparable length of terminal illness, hospice-care offers an economically attractive alternative to traditional terminal care. In assessing relative costs the base of comparison is important. If hospice-care is compared with conscientious conventional treatment for the terminally ill, including prolonged hospitalization, numerous
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diagnostic tests and the liberal use of radiation and chemotherapy, hospice-care is almost certainly more economical. On the other hand, if it is compared with virtually no care at all, it is clearly more expensive.
S. W.: Survival After Palliative Surgery for Advanced Intraabdominal Cancer. Am. J. Surg., 134:575, 1977. 3. Dunphy, J. E.: On Caring for the Patient with Cancer. N. EngI. J. Med., 295:313, 1976. 4. Eastman, M.: Shattering Myths About Hospice Care. Am. Pharm., 18:20, 1978. 5. Krant, M. J.: The Hospice Movement. N. Engl. J. Med., 299:
Conclusion There is still much to be learned about both the relief of symptoms and the optimal means of organizing programs of care for the dying patient. Experience with the hospice-care program at Church Hospital indicates that it has provided improved care for the terminally ill and their families at a reasonable cost.
546, 1978. 6. Lack, S. A. and Buckingham, R. W., III: First American Hospice. New Haven, Conn., Hospice Inc., 1978. 7. Mount, B. M.: The Problem of Caring for the Dying in a General Hospital: Can. Med. Assoc. J., 115:119, 1976. 8. Mount, B. M., Jones, A. and Patterson, A.: Death and Dying: Attitudes in a General Hospital. Urology, 4:741, 1974. 9. Ryder, C. F. and Ross, D. M.: Terminal Care-Issues and Alternatives. Public Health Rep., 92:20, 1977. 10. Saunders, C.: Hospice Care. Am. J. Med., 65:726, 1978. 11. Stoddard, S.: The Hospice Movement. Briarcliff, N.Y., Stein and Day, 1978. 12. Twycross, R.: Clinical Experience with Diamorphine in Advanced Malignant Disease. Int. J. Clin. Pharmacol., 9:189, 1974. 13. Wilkes, S.: Some Problems in Caner Management. Proc. R. Soc. Med., 67:23, 1974.
References 1. Brewin, T. B.: The Cancer Patient: Communication and Morale. Br. Med. J., 2:1623, 1977. 2. Brown, P. W., Terz, J. J., Lawrence, W. and Blievenicht,
DISCUSSION DR. GEORGE G. FINNEY (Stevenson, Maryland): When I read the paper, there were three things that struck me which I thought were very worthwhile. First, the team aspect: After all, in the operating room there is the operator, yes, but there are the assistants, the nurses, and others who enter in in such an important way that things could not do well without them; and in this way, with the different ones that can be called on for help, it's bound to be an asset of great value to the overall treatment of the patient. The second thing that impressed me very much was the fact that hospital and home are both utilized. The home part can make such a difference in so many individuals in the latter stages of life, and not only their well-being, but also in really getting along in a worthwhile way. The home also, of course, brings in the family, so that they have a chance to understand in a much better way the problems that the doctors face. Finally, the third thing that impressed me is that I can't help but believe that not only the physical but the psychological part of the patient can be handled so much better. In these days, you know, when there is some publicity that doctors are not thought of as well as they would like to think they could be, a lot has to do with the word that Dr. Zimmerman used- "communication" -and that is certainly one of the most important aspects. If through this team treatment the physical and the psychological side ofthe patient can be handled well, things are bound to go along as well as possible. I certainly am not a very good prognosticator, but I can't help but believe that there will be more units of this kind over the country, to the benefit of patients. DR. THOMAS N. P. JOHNS (Richmond, Virginia): Last May in Washington Senator Howard Baker of Tennessee presented the first Jack C. Massey Award of $50,000 to two individuals for their outstanding contributions to health care. One of these recipients was the Reverend Carlton J. Sweetser, a hospital chaplain and director of the hospice at St. Luke's, in New York. The opportunity to know this man and to hear the details of his program convinced
one who was a skeptic of the hospice idea that this, indeed, fills a void in which many find themselves at life's end. The hospital-based hospice program, as exemplified at Church Hospital and presented by Dr. Zimmerman, emphasizes that this is a "people caring for people" program. That is where the emphasis should be. Unfortunately, as Dr. Zimmerman indicates, the word "hospice" suggests a place, and for the past several months health planners have picked up hospice as a so-called cost saving alternative to hospital care. We are now facing-and this is true of the coming General Assembly in Virginia next month-the prospect of legislation being introduced to license free-standing hospices and bring them under certificate of need regulation, thereby making them another toy for the games health service agencies play. The suggestion that such free-standing places will help contain cost is patently ridiculous, and not only will capital and operating expenses in the face of uncertain future usage (I say "uncertain" because of suspected improvements in cancer control) but another layer of bureaucratic support and regulatory control will result, at predictably incalculable cost. But the hospice program, as described by Dr. Zimmerman, and based in hospitals, is really a need, I believe, and should be given a significant place in health planning. These programs, as Dr. Finney has said, should have our support in our communities, and at the same time, I think, we should oppose the proliferation of freestanding institutions for the terminally ill. That Dr. Zimmerman addressed himself to cost is a significant feature of his paper. It should be that surgeons participate as best we can in caring for those whose infirmities are no longer under human control, and this, I think, can best be done in programs such as described by Dr. Zimmerman.
DR. J. SHELTON HORSLEY, III (Richmond, Virginia): I appreciate having the opportunity to review Dr. Zimmerman's manuscript before he gave his excellent presentation this afternoon. At the Medical College of Virginia/Virginia Commonwealth University Cancer Center we are very interested in the hospice program. I
