Journal of Religion and Health, Vol. 22, No. 3, Fall 1983

The Hospice: Humane Care for the Dying V I N C E N T W. F R A N C O A B S T R A C T : The hospice movement arose as a reaction to the dehumanizing atmosphere of acute-care hospitals, where excessive utilization of life support equipment deprived dying patients of a meaningful vision of their destiny. Respecting the spiritual quest of the terminally ill for wholeness and dignity, the hospice concept prescribes the rendering of compassionate and pastoral care by a benevolent community of family, health care staff, friends, and clergy. Approximately 800 hospice programs are currently evolving in the United States. St. Mary's (formerly "Hillhaven") Hospice in Tucson, Arizona, offers the most comprehensive program of services, including home care, inpatient care, and artistic media through which the dying express their creativity. Numerous demonstration projects funded by several government agencies, principally the Health Care Financing Administration (HCFA), are expected to result in the legislative actions eliminating barriers to reimbursement of the cost of hospice services by Medicare, Medicaid, and other third-party payers. Existential analysis reveals the value of religion and spiritual support in enabling the dying to banish anxiety and muster the hope requisite for fully appreciating the authentic meaning of their destiny.

Existential background From time immemorial man has aspired to transcend the limitations of his earthly existence. Plato held that man's quest for immortality is fulfilled by generation, which leaves a new existence in place of the old.' Nicholas of Cusa wrote of the natural striving of all things to be in a better mode than the state their actual nature permits. Kant insisted upon a transcendental component in human understanding,'thereby including belief in personal immortality2 Feuerbach saw the anticipation of death as an instrument for gaining a fuller knowledge of being? Heidegger regarded the awareness of imminent personal death as the wellspring of purpose in life and the frame of reference for completion of authentic human existence.* More recently, the renowned theologian Karl Rahner has expounded upon the nature of temporality as a fundamental constituent of life, throughout the whole of which the "axiological presence" of death provides the basis of value affirmation--a deepened sense of time's unique preciousness bespeaking the irrevocable nature of every choice? The societal impact of these speculations helped lay the foundation for emergence of the hospice movement in the Western world. Vincent W. Franco, B. S., M. A., is Science Writer-Editor, U.S. National Institutes of Health and a Ph.D. Candidate in Bioethics, Georgetown University Graduate School. Requests for reprints should be addressed to Vincent W. Franco, Room 6c-04, Federal Building, 7550 Wisconsin Avenue, Bethesda, Maryland 20205. 241

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Rationale for the hospice For a millenium, death was a ritual presided over by the dying person among his friends, relatives, children, and neighbors. In the eighteenth century control of the ritual passed from the dying person to his family. Today the initiative has shifted from the family to the doctor and hospital team, who have become the "masters of death.'8 Modern medicine, with its armamentarium of sophisticated technology, is capable of artificially prolonging the lives of terminally ill patients beyond the point of meaningful existence/Under such circumstances, and imbued with the conviction that death is an enemy to be defeated at all costs, hospital staffs have undermined their own efforts by rending their patients' biologic functions from the totality of their being and depriving them of a natural vision of their destiny. The hospice movement evolved as a reaction against this dehumanization of the dying, as well as against unnecessary physical pain suffered in terminal illness. Basically, the hospice concept refers to either a place or service program respecting the spiritual quest of dying patients for wholeness and dignity, s It antedates the magnificent hospice of Turmanin in Syria (A.D. 475} and the more modest one founded in the port of Rome 1500 years ago by Fabiola (a disciple of St. Jerome} to care for pilgrims returning from Africa2 Subsequently, in the middle of the nineteenth century, Mary Aikenhead founded the Irish Sisters of Charity and charged them to care for the dying at a quiet nursing home in Dublin which she christened "hospice," consonant with her view of death as the beginning of a journey. Somewhat more than a decade ago, the ingenuity and resourcefulness of Dr. Cicely Saunders~~ rare embodiment of physician, nurse, and social worker--brought the modern hospice movement to fruition by establishing St. Christopher's Hospice in London, which has since served as model in the planning of many hospice programs in the United States and Canada. Linguistically, the words "hospice" and "hospital" share a common root meaning hospitality, or extending dignity to guests, but they designate significantly different approaches to health care. Whereas hospitals are committed to the acute-care system of efficiently curing disease of the temporarily ill, hospice programs emphasize controlling symptoms--in particular, excruciating pain--and pastoral care of the terminally ill. The latter do not view death as a failure of medicine, but rather as a logical conclusion to a life over which the dying person should retain control. Dr. Saunders recognized the inadequacy of care for the dying in acute-care hospitals, where the impersonality, sense of abandonment, bland surroundings, and imposing technology of health professionals preclude unification and integration of life experiences. She endeavored to correct this state of affairs by encouraging nurses and physicians to enrich their scientific knowledge with reverence for life and spirit in the thoughtful management of pain problems, anxiety, depression, and interrelations between dying patient and family.

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The underlying philosophy of compassionate care Compassion in medicine is best understood as a component of the complex social relations existing among physicians, patients, and the many other participants in health care. ~' In their scrupulously detailed book recounting the anguished trajectory of a solitary dying patient, Strauss and Glaser illuminate the need for such compassion. '2 The unduly prolonged course of this hospitalized patient, far in excess of the original prognosis, was dominated by intractable pain and accompanied by steady deterioration of relationships, not only between the patient and health care staff but also among members of the staff themselves. Notwithstanding the fact that quantity was considered to override quality of life remaining in this episode, sociopsychological improvements and greater accountability on the part of the health care staff could have provided a remedy conducive to more compassionate terminal care. A truly compassionate person cannot help questioning the ethics supporting prevention of death and prolongation of a lamentably wretched life. '3 The above account illustrates how allowing people to die in isolation, walled off from effective community with others under the guise of "medical necessity," contradicts a cardinal precept of hospice philosophy, which is grounded in the axiological significance expressed by Marcel in terms of dispombfllte," whereby life is consecrated through becoming alive to others. ~4 Toward greater equality of the patient-health professional relationship. In contrast to the compassion traditionally expressed by the physician in the form of authoritarian or paternalistic benevolence, new social definitions of death and dying, in addition to the Patient's Bill of Rights published by the American Hospital Association in 1972, entitle the patient to share in medical decision making. '~ The quality of compassion resulting from this greater mutuality of the doctor-patient relation should lead to greater respect for the dignity of the patient as subject, rather than object, of terminal care.

The current hospice movement in North America At the present time, numerous hospice programs modeled after the British experience are operational or in the planning stage on this continent. Progress in Canada during the last six years may be exemplified by the Palliative Care Service at the Royal Victoria Hospital in Montreal and the Hospice Care Program developed from a nursing model at Victoria General Hospital, Dalhousie University, Halifax. '6 The conceptual framework for these programs encapsulates within the dynamics of living the interrelated experiences gleaned by patient, family, and staff from participation in the dying and grieving processes.'7 In the United States, about 800 hospice programs are in various stages of planning and development in virtually every state, plus the District of Colum-

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bia? 8 In 1971, Hospice, Inc., was established in New Haven, Connecticut, as the first facility of itsd kind in the United States. It has a multidisciplinary home care team ministering to all needs of terminally ill patients. An inpatient facility was designed on a human scale and opened in the a u t u m n of 1979 as a 44-bed unit with a residential rather than institutional atmosphere. '~ Although the New Haven hospice received an annual grant of $800,000 for three years from the National Cancer Institute, the major obstacle to widespread implementation of such programs was financial, since third-party payers were reluctant to designate this kind of care as a reimbursable cost. However, more than 33 states in the United States have hospice societies. Studies by the U. S. Congress and Department of Health and H u m a n Services (DHHS} have resulted in legislative actions providing universal reimbursement for hospice care through Medicare and M e d i c a i d # Fueled by the perseverance of its able Executive Director, Dr. Josefina Magno, the National Hospice Organization in Washington, D. C., has published a definition which applies to most programs thus far developed in the United States: 2~ Hospice is a medically directed, nurse-coordinated program providing a continuum of home and inpatient care for the terminally ill patient and family. It employs an interdisciplinary team acting under the direction of an autonomous hospice administration. The program provides palliative and supportive care to meet the special needs arising out of the physical, emotional, spiritual, social, and economic stresses experienced during the final stages of illness, and during dying and bereavement. This care is available 24 hours a day, seven days a week, and is provided on the basis of need, regardless of ability to pay. Such care of necessity requires careful record-keeping for coordination of patient care as well as for use in education and research. Of equivalent import is the following official statement epitomizing hospice philosophy: ~ Pain control. The original B r o m p t o n m i x t u r e concocted at St. Christopher's in London is a potent cocktail containing diamorphine {heroin), cocaine, gin, sugar syrup, and chlorpromazine (a tranquilizer). 2~ St. Mary's uses a modified version of this consisting of morphine and prochlorperazine {for nausea). Meticulous attention to dosage and duration of action keeps pain in constant remission while the patient remains mentally alert. Control of other common symptoms. Although all the following measures may not necessarily be practiced at St. Mary's, the doctors at St. Christopher's prescribe prednisone for anorexia {loss of appetite), phenothiazines for vomiting, bronchodilators for dyspnea {breathing difficulties), benylin expectorant for cough, diazepam for anxiety, chorpromazine for confusion, amitriptyline for depression, nonbarbiturate sedatives for insomnia, stool softeners for constipation, and codeine or Lomotil for diarrhea. 2~ The role of children. In contrast to the restrictions of an acute health care setting, the family-centered approach at St. Mary's allows children to bring love and warmth into the lives of patients. It is believed t h a t watching the in-

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teraction between staff and patient will enable children to learn healthy attitudes about death and loss. Volunteers from all socioeconomic levels render a variety of supportive services as administrative assistants, bakers, receptionists, messengers, and entertainers. They are motivated by society's changing religious beliefs relating to kinship with the dying patient. Harnessing the creative energy of the dying. A distinctive feature of St. Mary's is its encouragement and support of creative communication by patients and their families. Creativity is the concentrated essence of living, and it frequently achieves m a x i m u m artistic expression under stress. Since confrontation with death is probably the greatest stressful experience in a person's life, the arts become a valuable source of inspiration and medium for expression of a dying patient's innermost thoughts, fears, and expectancies. 27In view of the documented association between psychological stress factors and the emergence of cancer cells, a wider acceptance of poetry writing and painting may conceivably reverse the steadily increasing incidence of cancer. At St. Mary's, the creative communications director, social worker, chaplain, and occupational therapist provide a multitude of artistic stimuli in the form of music, dance, drama, movies, and slide shows aimed at unleashing patients' creative energy for achievement of emotional and spiritual serenity during the uncertain period of transition. The clinical pharmacist discusses drug treatment plans with patients and families and makes necessary dosage a d j u s t m e n t s when indicated to optimize effect while decreasing side effects. He or she also monitors record-keeping and educates staff members concerning all aspects of pharmaceutical services, inservice programs, and drug information. The chaplain deals with spiritual and emotional problems of all patients and their families, regardless of religious affiliation. He also functions as a link to the health care team and joins with the priest, minister, or rabbi in planning a meaningful spiritual response to the patient's needs. Financial aspects of hospice care. Much of the success achieved by the English hospices may be attributed to the financial and moral support of a well-organized National Health Service. 28 Unfortunately, the United States lacks such a plan, as well as legislation guaranteeing reimbursement of palliative care. Death is a universal fact of life, and, whether or not it is accompanied by disease, dying is a normal process. We believe that every person is entitled to participate fully in this part of life in order to prepare for death in a way that is personally satisfactory. Hospice, as an option in the medical care system, exists not to postpone death, but, with special skills and therapies, to help the patient and family live as fully as possible. Death is not denied, but life is affirmed and lived until death comes. We believe that we are all dependent on one another; therefore, it is crucial, in the last few months of life, to help develop a caring community that can provide comprehensive services to patients and their families.

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Organization of the prototype American hospice. American hospices presently in operation include: St. Luke's Hospital (New York City), the first major American health care institution to establish an inpatient palliative care program; the Pennsylvania Hospital program, which follows the Royal Victoria approach; 23 Calvary Hospital (Bronx, New York); Hospice, Inc. (New Haven, Connecticut}; Marin (Marin County, California); Mercy Hospice (Oxnard, California); St. Mary's (formerly "Hillhaven," in Tucson, Arizona); St. John's (Springfield, Illinois); HAVEN Volunteers of Annandale (Virginia), Schenectady (New York), and Pensacola (Florida}; the Montgomery County Hospice Society (Maryland}; Kaiser Permanente Medical Center (Hayward, California); and two cooperating hospice boards in San Francisco. Becuase it is the only autonomous hospice offering a comprehensive program of care in the United States, St. Mary's Hospice in Tucson, Arizona, will be described in detail as representative of what can happen in this country. St. Mary's Hospice, a 39-bed facility offering care to terminal cancer patients since April 1977, was developed by the Hillhaven Foundation, Tacoma, Washington. This hospice is the product of successful collaboration by the Foundation with the University of Arizona College of Medicine, Health Sciences Center, College of Nursing, College of Pharmacy, and College of Business and Public Administration. The Foundation is licensed in a special bed category as a "Special Hospital-Hospice," which exempts patients from having to stay in a hospital for three days to establish Medicare eligibility before entering the hospice. 23 In contrast to the traditional hospital devoted to rehabilitation, cure, and restoration of normal function, this hospice contains no sophisticated life-support equipment and is oriented solely to compassionate care of the dying. St. Mary's provides a program of service to dying patients for whom aggressive therapy is deemed no longer appropriate. This medically directed program offers palliative and supportive care to patients and their families in collaboration with the patients' attending physician. It integrates the hospice into a community service network with features of outreach to referring hospital or physician, home care, adult day health care, inpatient services, and after-care for families of deceased patients. Home care. The hospice contracts with the Visiting Nurse Association to provide a full range of home health services supervised by the medical director and coordinated by the "facilitator," who is a registered nurse with a master's degree in counseling and guidance. 24 Emphasis is placed upon instruction of the family in supportive care and special nutritional needs of the dying, as well as meeting the patient's need for legal and/or financial assistance from community agencies. St. Mary's now delivers home care services independently. Inpatient care. When the patient can no longer be managed at home, he or she is transferred to the 39-bed hospice inpatient facility, which is licensed as a certified nursing facility. Staff comprises nurses, a primary care person, occupational and physical therapists, a social worker, a director of creative communications, and a director of an extensive volunteer service. In this facility, symptom control programs are carefully monitored.

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Traditionally, health care financing mechanisms in this country have been oriented to curative care. However, the ominous projection by the American Cancer Society that one in four Americans now living--55,000,000 citizens-will eventually have cancer has induced the Federal Government, through D H H S , to support the hospice movement via several programs. 2~The Health Care Financing Administration (HCFA) is currently funding a two-year demonstration project at 26 home health agency-based, hospital-based, and freestanding hospices across the United States, with arrangements for reimbursement for services provided to Medicare beneficiaries and Medicaid recipients. H C F A is also contracting with Brown University for independent evaluation of cost, utilization, and quality of care, in order to develop flexible approaches to third-party reimbursement. I have already mentioned the three-year contract awarded by the National Cancer Institute (NCI) to Hospice of New Haven for a demonstration program of continuing home care for cancer patients. NCI has published data generated by similar three-year contracts for testing feasibility of the hospice concept at St. Mary's Hospice in Tucson, Kaiser-Permanente Hospice near Los Angeles, and Riverside Hospice in New Jersey. These data, 3~revealing an average cost of $73 per hospice program day per patient, are highly cost-effective and far below the figures recorded by Kassakian et al. 3' in an earlier study of cancer patients at nursing homes and hospitals in rural Vermont. In addition, the Administration on Aging, Office of H u m a n Developoment Services, and National Institute on Aging are funding projects exploring the integration of hospice services into geriatric medicine, reimbursement of such services under the Social Security Act, and the familial impact of bereavement. In 1979 the Blue Cross and Blue Shield Associations had adopted an interim position on coverage and reimbursement of hospice care, pending the outcome of 200 pilot projects, a2 At that time, they estimated that keeping a terminally ill patient in a hospital during the dying process would cost $15,000- $20,000, whereas home care for the same period would cost less than $1,000. 33 Notwithstanding this optimistic projection, however, third-party payers are still concerned about such problems as the best setting for hospice care, the absence of approved standards for evaluating the quality of this modality of care, the appropriateness of bereavement coverage, and competition for scarce community resources. In an a t t e m p t to remedy part of this situation, the Joint Committee on Accreditation of Hospitals launched an 18-month project aimed at developing quality standards and a model accreditation program for hospice services. If these problems are adequately addressed, the hospice concept may soon enjoy financially sound entry into the mainstream of American health care delivery. The spiritual d i m e n s i o n o f hospice care. The conception of "spiritual supp o r t " characteristic of a hospice program is admittedly ambiguous, a4 In one sense, it may be interpreted in terms of respect for the religious viewpoint of a terminally ill patient. In another sense, it may refer to the service provided by a chaplain or clergyman. In a third sense, it may be identified with a quality of care provided by an institution under religious authority. These interpreta-

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tions are consistent with a statement by the National Hospice Organization depicting the hospice movement as ecumenical yet based on fundamental precepts derived from a common understanding of the nature and purpose of religion within human experience. In the context of the dying experience, religion has intrapersonal, interpersonal, and eschatological directions. 35 Many ethicists would agree that humane approaches to terminal care assume a religious perspective. The scope of the adjective "religious" embraces something far beyond a sense of institutionalized belief. Etymologically, "religious" stems from re-ligio, the core being ligo, which means "to fix or connect." Thus, religion connects one to other people {community, fellowship} and to events within one's own life {story}, but it also "fixes" one and thereby provides a foundation for growing beyond the secular toward the holy. Accordingly, the conjoined intrapersonal, interpersonal, and eschatological directions of religion drive one more deeply into the world and beyond the world in the ethos of the dying experience2 ~ If one accepts a classic definition of death as the departure of spirit or activating principle of life upon separation of material substances from spiritual forces, then spiritual dimensions m a y be viewed as intensely personal, unifying principles of a patient's life, and these would proceed along the intrapersonal direction of rehg~on vis-a-vis the dying experience. Although what is operative here is not necessarily a specific creed prescribed by an organized religion, it may be a spiritual frame of reference reminiscent of the aspiration for transcendence viewed by Freud as a conscious denial of mortality. 37 However, Freud erroneously equated this denial with a quest for immortality as a synonym for one's " e n d " - - a word with two different meanings which he failed to distinguish. When understood in the sense of the Greek word, telos, "end" means purpose or destiny of fulfillment of design. By contrast, "end" understood in the sense of the Latin word, finis, means termination or cessation. Thus, appreciation of this vital distinction makes it possible for a dying person to be viewed as denying mortality and thereby sustaining a hope of destiny rather than asserting immortality, and yet contemporaneously also accepting the inevitable cessation of his life2 s The interpersonal direction of religion in the context of the dying experience affects the unifying and integrating dimensions of living, thus calling into play the supportive skills for assisting patients, families, and hospice staff in their collective efforts at achieving wholeness. These persons need time to reflect upon the mysteries of life, suffering, and death, and to integrate their experiences with those of the terminally ill. The eschatological direction of religion finds concrete realization in pastoral care, which by definition entails the exercise of ministry toward those who wish to die in the faith by fulfilling the divine expectation of reciprocation for the gift of life2 ~ A perspective of reconciliation. Pastoral care respects the freedom of the dying person to accept all phases of his or her life--the past, the present, and the future. '~ Reconciliation with the past challenges a person's negative image of God as a vengeful deity and encourages love of both self and reality, so as to dispel any guilt or shame associated with the burdensome memory of unful9

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filled earthly goals. Dealing pastorally with the present requires sensitivity to the external manifestations of terminal illness as well as the individuality of survivors. In looking toward the future, it would not be within the context of pastoral care to attempt to convince the patient, family, or staff of the existence of an afterlife. Rather, the reassurance conveyed should enable the patient to achieve serenity in the realization that he or she has made acceptable use of his or her talents, regardless of failures or successes.

Conclusion The hospice prescription affords physical, psychological, and spiritual care to dying patients whose wholeness comes to flourish in a benevolent community of family, staff, and friends. Through the compassionate intercession of this community, the dying are inspired to banish their anxiety by engaging in the recollections and anticipations which are the media of the will to endure in the uncertainty of their passage." Mastery of this process generates hope, which suffuses the closing moments of life with a fullaess of being that permits recovery of meaning and heightened appreciation of finitude. Restoration of the plenitude of being which is the object of hope transcends the reach of calculated efforts. '2

References 1. Metzger, A., Freedom and Death. London, Chaucer Publ. Co., Human Context Books, 1976. 2. Parsons, T., "Death in the Western World." In Reich, W. T., ed., Encyclopedia of Bioethics, Vol. 1. New York, Free Press, 1978, p. 257. 3. Butler, R. N., Why Survive ? Being Old in America. New York, Harper and Row, 1975, p. 380. 4. Heidegger, M., Being and Time {1927), Macquarrie, J., and Robinson, E., trans. London, Library of Philosophy and Theology, SCM Press, 1962. 5. Rahner, K., On the Theology of Death. New York, Herder & Herder, 1961. p. 77. 6. Walter, N. T., The Coming of Death in America: Concepts in Transition. Washington D. C., National Clearinghouse on Aging, Administration on Aging, Department of Health, Education & Welfare, 1976. 7. Corbett, T. L., and Hal, D.M., "Searching for Euthanatos: The Hospice Alternative," Hospital Progress. 1979, 60, 3, 38-41. 8. Davidson, G. N., "In Search of Models of Care." In The Hospice, Development and Administration. Washington {State}, Hemisphere Publishing Co., 1978, pp. 145-161. 9. Stoddard, S., The Hospice Movement. New York, Stein and Day, 1978. 10. Saunders, C., "Care for the Dying," Patient Care, 1976, 3 6. 11. Barber, B., "Compassion in Medicine: Toward New Definitions and New Institutions," New England J. Medicine. 1976, 295, 17, 939-943. 12. Strauss, A. L., and Glaser, B. G., Anguish. A Case History of a Dying Trajectory. Mill Valley, Calif., Sociology Press, 1970. 13. Browning, M. H.. and Lewis, E. P., The Dying Patient: A Nursing Perspective. New York, American Journal of Nursing Co., 1972.

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14. Marcel, G., "'Sketch of a Phenomenology and a Metaphysic of Hope"; "Value and Immortality." In Homo Viator. New York, Harper & Row, 1962. 15. Crane, D., The Sanctity of Social Life: Physicians'Treatment of CriticaUy Ill Patients. New York, Russell Sage Foundation, 1975; Pellegrino, E. D., "Medical Ethics, Education and the Physician's Image," J. Amer. Medical Assoc., 1976, 235, 1043-1044. 16. Wilson, D.C.; Ajemian, I.; and Mount, B.M., "Montreal {1975}--the Royal Victoria Hospital Palliative Care Service"; Wylie, N. A., "Halifax (1976)--Victoria General Hospital: A Nursing Model." In The Hospice, Development and Administration, op. cit., pp. 3- 19; 21-39. 17. Wylie, op. cit., pp. 21-39. 18. National Health Standards & Quality Information Clearinghouse Information Bulletin, Special Topic: Hospice Care. Washington D.C., Health Care Financing Administration, 1981. 19. Goldenberg, I. S., "Hospice: To Humanize Dying," Bull. Amer. College Surgeons, 1979, 64, 4,6-9. 20. Briendel, C.L., and Boyle, R.M., "Implementing a Multiphased Hospice Program," Hospital Progress, op. cir., 42-45. 21. Flexner, J.M., "The Hospice Movement in North America--Is It Coming of Age ?" Southern MedicaI J., 1979, 72, 3, 248-250. 22. National Health Standards & Quality Information Clearinghouse Information Bulletin, o19.cit. 23. Mclntier, T. M., Sr., "Hillhaven Hospice: A Free-standing, Fanfily-centered Program," Hospital Progress, o19. cit., pp. 68-72. 24. Ibid 25. Holden, C., "Hospices: For the Dying, Relief from Pain and Fear," Science, 1976, 193p. 389. 26. Baines, M., Drug Control of Common Symptoms. London, St. Christopher's Hospice 1976, to the present. 27. Rogers, B_ L., "Using the Creative Process with the Terminally Ill." In The Hospice, Development and Administratio~ o19. ciL, pp. 123-126. 28. Corbett, T. L., and Hal, D. M., op. cit~, pp. 38-41. 29. National Health Standards & Quality lnfornmtion Clearinghouse Information Bulletin, op. cit. 30. Kay, L. L., "A Cost Analysis of Three Hospice Programs," Report of National Cancer Institute, 1981. 31. Kassakian, M. G., et aL, "The Cost and Quality of D)~ng: A Comparison of Home and Hospital," Nurse Practitioner, 1979, 4, 18-20. 32. Hollander, N., and Ehrenfried, D., "Reimbursing Hospice Care: A Blue Cross and Blue Shield Perspective,*' Hospital Progress, 1979, 60, 3 54-56. 33. Flexner, op. cir. 34. Davidson, op. cit. 35. Flexner, op. cit_ 36. Brady, E. M., "Telling the Story: Ethics and Dying," Hospital Progress, 1979, 60, 3, 57-62. 37. Freud, S., "The Major Works of Sigraund Freud," Encyclopedia Brittanica, Chicago, 1952. 38. Davidson, op. cit. 39. Parsons, op. cir., p. 257. 40. Fath, G., "Pastoral Care and the Hospice," Hospital Progress, 1979, 60, 3, 73-75. 41. Kierkegaard, S., Concluding Unscientific Postscript, Swenson, D. F., and Lowrie, W., trans. New Jersey, Princeton University Press, 1944, p. 147. 42. Marcel, op. cir.

Supplementary

References

Abbott, J. W., "Hospice," Aging, 1978, 289-290 38 -40. Agich, G. J., "The Ethics of Terminal Care." In The Hospice, Development and Administration, Washington {State}, Hemisphere Publishing Co., 1978, pp. 163 - 171. Alsofrom, J., "Hospice Way of Dying--at Home with Friends and Family," Amer. Medical News, 1977, 20, 7 -9. Callan, J. P., "The Hospice Movement" {Editorial), J. Amer. MedicalAssoc., 1979, 241, 6,600. Cape, R., "The Philosophy of Continuing Care." In Aging: Its Complex Management. Hagerstown, Maryland, Harper & Row, 1978, pp. 213- 229.

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Craven, J., et al., "Hospice Care for Dying Patients," Amer. J. Nursing, 75, Oct, 1975, pp. pp. 1816-822. Dunphy, J. E., "Rising Above Suffering and Death," Bull. Amer. College Surgeons., 1979, 64, 4, 10-11. Editorial, "The Hospice: An Alternative," J. Amer. Medical Assoc., 1976, 236, 18, 2047. Editorial, "Secretary Califano Pledges Support for Hospice Movement," Aging, 1978, 20-21, Editorial, "Treating Patients in ~heir Homes--Often Cheaper, Often Better," U. S. News and World Report, 1976, p. 73. Erikson, E., Insight and Responsibility. New York, W. W. Norton & Company, 1964. Feifel, H., The Meaning of Death. New York, McGraw-Hill, Blakiston Div. _ _ , New Meanings of Death. New York, McGraw-Hill, Blakiston Div., 1977. Fletcher, John C., "Ethics and the Costs of Dying." In Milunsky, A., and Annas, G. J., eds., Genetics and the Law, 2. New York, Plenum Press, 1980. Garret, D. N., "The Needs of the Seriously Ill Patients and their Families: The Haven Concept," Aging, 1978, 12-19. Gurewitsch, E., "Calvary Hospital: The Newest Building, the Oldest Organization for the Terminally Ill," Aging, 1978, 32-37. Guthrie, D., "Dr. Ki~bler-Ross: A Positive Acceptance of Death," Bull. Arner. College Surgeon, 1979, 64, 4, 12- 13. Hinton, J., Dying. Baltimore, Penguin, 1967. Holden, C., "Pain, Dying and the Health Care System," Science, 1979, 203,984 -985. Kass, L. R., "Regarding the Use of Medicine and the Pursuit of Health," The Public Interest, 1975, 40, 11-42. Kaufman, W., "Existentialism and Death." In Feifel, H., ed., The Meaning of Death. New York, McGraw-Hill, 1959, pp. 39-63. Koestenbaum, P., The Vitality of Death: Essays in Existential Psychology and Philosophy. Westport, Connecticut, Greenwood Publishing Co., 1971. Laney, J. T., "Ethics and Death." In Mills, L. O., ed., Perspectives on Death. Nashville, Tennessee, Abingdon Press, 1969, pp. 231-252. Nighswonger, C. A., "Ministry to the Dying as a Learning Encounter," J. Thanatology, 1971, 1, 2, 101-108. Rahner, K, "Christianity and the New Man," Theological Investigations. Baltimore, Helicon Press, 1966. Shimkin, M. B., "Implementation of the Hospice Concept." In Science and Cancer. U. S. National Institutes of Health, 1973, pp. 15-568. Thielicke, H., Death and Life. Philadelphia, Fortress Press, 1970. Veatch, R. M., Death, Dying and the Biological Revolution. New Haven, Yale University Press, 1976. Wentzel, K.B., "The Dying Are the Living," Amer. J. Nursing, 1976, 76, 6, 956-957.

The hospice: Humane care for the dying.

The hospice movement arose as a reaction to the dehumanizing atmosphere of acute-care hospitals, where excessive utilization of life support equipment...
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