The Hospice Concept in Health Care

 Kathleen Ann Allen

The hospice movement has been receiving a great deal of attention lately. Care of the dying has become the by­line for any professional as well as non-professional writers. You are sure to find at least one article in any current journal for health professionals devoted to the care of the terminally ill. Television has presented news miniseries and specials on the needs of the dying, and syndicated columnists, such as Sylvia Porter, have written on the subject. Why all this interest in the dying? 4hy all this interest by the health professionals who have been dealing with dying clients for centuries? One answer has been to attribute this recent attention to the fact that people are now living longer than even a half-century ago. However, the answer is quite likely much more complex than that. There is currently an internal evaluation process being carried out in most health related facilities. These evaluation procedures have evolved from government and con­sumer demands over recent years. It has become a recognized fact that within the medical and nursing professions not enough attention has been given to the care of the dying and/or the handling of the dying client. Attempts are made to correct this dilemma. Medical and nurai1:,; schools are now offering courses and recommending them to their students on such topics as "Perspectives on Death and Dying." They have not reached a required status in most college curricula; however, death and dying is at least ac­cepted as a topic to be discussed in the professional pre­paration of the future health care practitioners in this country. 

When considering the health care needs of the dying today, many think of the work of Dr. Elisabeth Kubler-Ross with her theory of the Stages of Death and Dying, and the work of other thanatologists, and most recently the hospice movement. This work will focus on hospice. Just what is the Hospice concept and what are its roots?

 The term "Hospice" comes from the Latin root Hospes which means both host and guest. It implies, therefore, a mutual caring between practitioner and recipient. The first Hospice in modern times is the well-known St. Christo­pher's in London from which the American Hospice movement grew. However, the original hospices date back to medieval times. They were way stations established by religious com­munities to provide care and personal attention to those who became sick or wounded on their travels to the Holy Land. They became famous for the excellence and compas­sion of the care given in them. They were the historical institutions from which more specialized modern institu­tions such as hotels and hospitals have evolved. Thus, Hospices have come to be remembered as a community for so­journers along the way, a place of replenishment, refresh­ment, and care. The reigning moral theme at the time of the medieval hospices was "as long as you do it for the least of my brothers that you do unto me." Whatever the moral tone of our contemporary society, the Hospice movement seems to be catching on. We will have to face the inevit­able one day -- our own death. We can deny it, cry about it, worry about it, laugh it off, or we can be prepared for it. Realizing that no one has found a "way out" throughout the centuries, many today are trying to insure that they will die with dignity and with others around who genuinely care for them. That is what Hospice workers have been try­ing to accomplish. 

For anyone who has ever had a loved one die in the cold, sterile atmosphere of a hospital, it isn't easy or necessarily dignified. It is not entirely the fault of the medical and nursing staff either. I believe that I can say that as a nurse who has been in life and death situations throughout my career. Knowing someone is going to die and knowing all that you have been trained to do is useless in terms of prolonging that person's life, is not only the most frustrating and helpless feeling, but also one of the saddest that a nurse has to face. Nurses must deal with those feelings early in their careers to be of any benefit to the dying clients entrusted to their care. 

Today, Hospice can be equated to a special way of car­ing for those incurably ill, and its goal is to blend the best of professional care with the most personal service possible so as to meet ongoing client needs for comfort and relief even when a cure is no longer possible. Hospice was developed to supplement, not replace, existing medical facilities or services. The staffing of the Hospices is primarily volunteers who are carefully selected and trained, and made up of both professionals and non-professionals. 

The purposes of the Hospice approach, an interdis­ciplinary total care approach to the care of the dying, are as follows: to establish a community of caring for clients diagnosed as having an incurable chronic illness with a life expectancy of six months or less and for their fami­lies; to help ease the physical and psychological discom­forts inherent in such illness and death; and to assist families during the bereavement period which includes follow-up care after the death of the loved one. The Hospice ap­proach is family oriented, with the family as the unit of care. It is a highly people-oriented approach also, i.e., an interaction and caring between humans. Hospice is not a place, but a concept or program of health care. The Hos­pice approach is dedicated to removing the stigma of death and isolation that accompanies the institutionalized way of dying. Dr. Leigner, a specialist in radiation therapy at St. Luke's Hospital, N.Y.C., states hospice "teaches the realization and acceptance (consciously of dying and death as part of being born and part of the struggle of life." 

The hospice goals vary within each institutional setting. The general or overall goals would include the following: to help the client live as fully as possible, conscious and free of pain, and in control; to support the family as the unit of care; to keep the client at home as long as appropriate; to educate health professionals as well as lay people, to supplement, not duplicate, existing services; and to keep costs down. The concept of remaining home is the “ideal” Hospice approach. 

Dr. Cicely Saunders made the Hospice synonymous with more humane care of the dying and good medical practice. In 1967, Dr. Saunders founded St. Christopher's Hospice in London, England. It is indeed a way station for the dying -a place where people can go in the final stages of degenera­tive diseases. It is a place of warmth and support. St. Christopher's has a charitable foundation; it is funded by friends and families. A client, however, is never turned away because of financial inadequacy. 

Dr. Sylvia Lack began the United States hospice Move­ment after working at St. Christopher's and St. Joseph's in London. The design of the New Haven Hospice accommodates the primitive fear of and revulsion for the dead body. This hospice is the first here in the United States to be closely modeled after St. Christopher's. The Federal government's attitude toward the birth of the Hospice movement in the United States has been one that is cautious and investiga­tory by nature, but finally approving. There are at this time 300 operating Hospices in the United States, with more than 125 planned. 

In the United States, death has finally come out of the closet. In the past, we did not know when to let go. Our society, including trained physicians, denied death. We still have a need to keep clients "biologically alive" with modern technology. Medical and nursing staffs haven't looked at dying clients realistically. All they saw in the death and dying around them was failure and the terror of their own inescapable death -- their mortality. The only health care deemed acceptable was successful care -- care that saved a life. 

The group best suited and motivated to take the lead in the provision of care and comfort for the dying seems to have been religious communities or religious lay groups. An ex­ample of an earlier undetected "Hospice" in the United States is Calvary Hospital in the Bronx. It was founded in 1899 by Mrs. Annie Storrs and a group of Irish Catholic laid women for the care of the destitute, dying of cancer. It is now owned by the New York Archdiocese, and it is the only hospital in New York State exclusively for the terminally ill. This recently modernized hospital can house up to 200 clients. It is a voluntary, non-profit facility. Although a pioneer in the care of the dying, it still remains a Hospice experience within a hospital setting. Philosophically little has changed in 82 years at Calvary. V. Dunigan, 5 C.M. referred to Calvary Hospital in the May, 1980 Catholic Digest as a place "where the dies come. 

None of the New York area Hospice programs at present fulfill the "ideal." The Hospice program that is closest to the "ideal" is the one in Riverside, New Jersey. It was set up in January of 1977. It is a program of medical, spiritual, and social support services established to enable terminally ill cancer clients to die at home. Its philosophy is to pro­vide humane, compassionate, palliative medical and social care to clients with cancer and their families. Its primary goals are to provide support necessary to help the client die with dignity and minimize the destructive impact of the cancer death on the surviving family members. The Riverside Hospice has a back-up in-patient unit with the home care pro­gram receiving the primary emphasis. This particular hospice is funded through the National Cancer Institute. The dying clients and their families meet with the hospice team initially to identify the problems, set goals, and make any necessary referrals, and then meet as often as necessary. 

There are a variety of programs markedly diversified that have been labeled as Hospices. The American Hospice Movement recognizes several variations from the "ideal" home-­based set-up. St. Luke's in New York City was organized in 1975; it was the first hospice program incorporated into a United States medical center, and it was the second hospice established in this country (New Haven being the first). It is open only to adults; it has an in-patient and an outpatient approach. Influenced by Dr. Saunders, pain manage­ment with medications is geared toward maintaining an alert and rational client for as long as possible. This is a voluntary, non-profit hospital. The goal of this integrated, consultative Hospice team within the hospital medical center is to improve the quality of life that remains for their clients. 

Twenty-six Hospice programs had been selected initially by the Health Care Financing Administration of HEW as two year demonstration projects for reimbursement through Medicaid and Medicare. One of the fifteen in New York State participating; in this project has been the Brooklyn Hospice, sponsored by the Metropolitan Jewish Geriatric Center. It is a 50 bed in-patient facility with out-patient services too. Its goal is to foster the spiritual, emotional, and physical well-being of dying clients and their families. 

North Shore Hospital in Manhasset in Nassau County has an H.O.M.E. (Home Oncology Medical Extension) approach for ad­vanced cancer clients wanting to be treated at home. They have a mobile van equipped with lab and medical supplies. Their outreach program offers chemotherapy. This program was one of the pioneers in alternatives to hospitalization for dying clients. 

Another Hospice program is St. Rose’s free home for in­curable cancer run by the Hawthorne Dominicans which was built in 1912. It houses 60 clients. There are no lab or work-up facilities on the premises. Their goal at St. Rose's is to keep the client pain-free and alert. Pain medications when needed are given before the patient has to request them as it is done in St. Christopher's. This facility will accept anyone who is unable to pay for care anywhere else. St. Rose's was founded by Rose Hawthorne, daughter of Nathaniel. It relies on the donations of the sympathetic public. It is one of many homes run by these Sisters in this country. 

Mercy Hospital Hospice in Rockville Center in Suffolk County is family centered with volunteers an integral part of the program. It is part of the general hospital setting, i.e., a unit with its own staff. 

The first Hospice in the world planned for children is St. Mary's Hospice in Bayside, Queens. It emphasizes the concept, more than the institution. St. Mary's program will have ten beds, and 60-70 out-patient department clients. There will be active in-service education programs. There will be a cost of $125/day. However, at the outset it will be a funded project; therefore, there will be no charge to clients. There will be continuous outcome, process, and structure evaluations done in the program. The approach taken with the children will be one characterized by honesty.

Thus, one can see the "variations on the theme" concept applied to the set-up of a few Hospice programs in the New York City vicinity. The main similarity is a caring community of people trained in their various skills and offering a ser­vice and fellowship, not only to the client, but to the en­tire family unit. There are no prejudices in the Hospice Movement as to race, creed, or financial abilities. Since all of us will one day die, all of us are entitled to the same care and concern from our fellows. This caring community operates on its own principles, autonomous in terms of its professional procedure (Stoddard, 1980). The major difference perhaps from this way of caring for the dying from the well-­known hospital approach is that the Hospice is planned as a therapeutic environment designed from the client's point of view. What makes Hospice a better way of dying and a "good death" is the insistence upon fitting care to the client, rather than forcing the client into the relentless routine of some institutions, that are basically designed and run for other purposes. "The Hospice provides individuals with the process of pure being, as it is acted out in giving and re­ceiving of human love" (Stoddard). This is the key to the Hospice movement and the Hospice success. 

There has long been a need to talk about death and dying and that need continues even today, but we also need to begin to take action on those thins that will enable us to improve the care of the terminally ill. Death need not, nor should it, he experienced alone. 

The future of Hospice is bound up in the growing aware­ness that this is a better and more humane attitude than that which has preceded it.  

Hospice has developed much recognition these days, so much so that there is a National Hospice Organization in McLean, Virginia, 22101. There is also a Hospice Institute for edu­cation, training, and research, in New Haven, Connecticut, 06511. Hospice Inc. in Connecticut is a non-profit corpora­tion with voluntary members. The institute has been able to estimate the cost of the hospice care to be $450 over a 3 month period for home care, which is far cheaper than hospital care. 

Nurses are interested in the people-oriented type of care in the Hospice setting, which attracts capable, caring nurses. The nurse's role in the Hospice is as diversified as it is in other nursing settings. The nurse is responsible for pain and symptom management, teaches the family basic nursing care, lends emotional support to client and family through close of life and through bereavement, and makes home visits. The nurse, in this type of care, needs to listen, touch, and hear, be thoughtful and competent, open and willing, use silence and be honest. Since Hospice is a way of life -­ a commitment--those attracted to this special caring usually have some commitment to spiritual values, and are outgoing individuals who enjoy helping and caring for others. As in most nursing services, hospice clients require 24 hour a day, 7 days a week coverage. The nurse needs to be accessible to the client, and have a kind of candor and conscience in fill­ing the information gap.

As for physicians, Dr. Twycross at :sir Michael Sobell House in Oxford, England drew up what he called the Ten Com­mandments for doctors dealing with the pain of cancer. 

I previously mentioned as part of the nurse's respon­sibility symptom and pain management. Let me expound on that statement in this section. Symptom control can be divided into three main categories: 1) physical, e.g., pain, nausea, vomiting, etc.; 2) emotional, e.g., helping the client and family cope with the distress accompanying impending death; and 3) spiritual, an integral part of the program, with atten­tion to human spiritual concerns a priority. Pain control varies as follows: 1) narcotics, 2) precision dosage and tim­ing, 3) morphine, 4) the "American Hospice Mix" which con­tains morphine 5-90 ms's-, cherry syrup to 10 mls, and Com­pazine 5 mgs. (This is derived from the "Brompton's Cocktail" used in Britain, which is a liquid formal-: of herein, cocaine, alcohol, syrup, and chloroform water), and 5) hypnotics, and 6) adjuvant drugs (e.g., phenothiazines). Addiction is not an issue in a Hospice; the quality of the life remaining for the client is the key and real issue. Since the major concern of the Hospice is to keep the client alert and responsive at the same time pain and nausea free, the prescribed drugs are not given prn (whenever necessary) as is the usual method of dispensing pain medications. The proper time to give a dying client pain medication is before the client feels any pain, eliminating, therefore, the anxiety of the expectation of the pain. This requires close monitoring and continuity of care and personnel. The client will usually then remains as comfortable and peaceful as possible until he or she dies. For many clients “it is not death they fear, but unspecified, unlimited pain” (Lowell). Thus, how the pain medication is given is far more important than what is actually given. 

Another key to the success of the Hospice movement is the lack of restriction in the area of visiting clients con­fined to the "non-ideal" Hospice outside the home. No re­strictions are placed on the volume of visitors, as long as the client can tolerate it, nor the age of visitors including infants and small children; even pets are allowed to visit if that will add to the client's peace and comfort, and no re­strictions are placed on visitors as to time, since time is very precious to the dying person. Recent studies have shown that survivors who do not view the body at the close of their loved one's life have difficulty in separating from the dead and can become long-term, chronic grievers, making them susceptible to higher morbidity and mortality rates. Moreover, there is much to be learned from the dying that would be lost if they are kept isolated. It is the dying who teaches us the real meanings of life.

 Hopefully, the Hospice movement is an alternative method of care for dying clients that is more positive and more humane. The hospice accepts the client's death as a natural end to the client's life. The hospice team assists the client and family through the various stages of dying and the ex­periences associated with death, after first coming to grips with their own attitudes, concepts, and fears of death. The caring community helps and supports the client through their psychological and emotional reactions to dying, e.g., anger, guilt, shame, grief, depression, and acceptance; they recognize the client's coping mechanisms, e.g., denial, regression, and intellectualization as part of that dying client's death pro­cess. They enforce guidelines for interacting with a dying client such as: maintaining the client's dignity (respect as a person), helping the client feel secure (a need for trust), and maintaining the client's hope (short-term goals). The Hospice team preserves the dying person's bill of rights which was established back in 1975. The Hospice approach eliminates the "living dead" syndrome so frequently seen in hospital settings (the dying client who waits alone, isolated, and already mourned by the family members in an emotionally and physically sterile environment). The control over one's life is important even if one knows that death is near and inevitable. The Hospice approach has added new dimensions to the nurse-dying client relationship. 

The United States is on the verge of a Hospice prolifera­tion. As the American health care system progresses away from the renowned hospital setting and moves back into a community-­based system, as it is predicted, the Hospice movement will probably be strengthened. With or without the passage of the National Health Insurance Program, Hospice bills will still be paid for in part by such plans as Blue Cross/Blue Shield, Medicare, and Medicaid as it is currently being covered. 

The scope of this paper thus far has been the Hospice as the future hope of the dying client's right to die with dignity. Drawbacks and imperfections in this system are also evident to the probing mind. One prime example is the setting up of the Hospice program as yet another specialty in the medical world. Nurses and physicians have departmentalized themselves into these specialties at the expense of the holis­tic approach to health care. Individual practitioners tend to remain in one chosen aspect of the field until burn-out occurs. Burn-out has also been experienced as a recurrent theme, especially in Hospice care. How long can one work with only the dying before depression or frustration sets in? An apparent solution to this problem would be a rotation schedule for medical and nursing staffs to prevent one from becoming too specialized or burnt-out. However, this would defeat the purpose of the commitment and continuity needed for Hospice care. As in every other area of the medical/nursing pro­fessions, the skills utilized can also become mechanical and rote in the Hospice movement. In Hospice care the need for hope, freshness, and diversity is apparent. Another possible drawback of this type of health care is an emotional over-­involvement with the clients with the resultant: "each man's death diminishes me." How much can one give to another with­out paying a price? It is very draining to continually be supportive, accept the anger of others, and constantly face one's mortality. The caring required in Hospice care involves the willingness to do the unlovely -- a chief ingredient in this type of commitment (Hoskovec,8 Administrator of St. Mary's Hospital, Bayside, Queens.) How long can this willing­ness thrive in a selfish society? 

Another potential problem is the exploitation by commer­cial interests who would convert nursing homes, geriatric centers, and wards into "nominal" hospices in order to take advantage of a trend without any real preparation for, know­ledge of, or commitment to the ideals of the hospice movement.

In summary, there has been change in the approach of the health care practitioners in the care of the terminally ill clients. The Hospice approach has been offered as an alter­native to the existing pattern of avoidance and denial in the care of the dying. This approach is still in its formative years and has a long way to go before it is a widely accepted, preferred approach with minimal drawbacks that realizes the ideals of the Hospice movement as expressed by Dr. Saunders (1967): "You matter because you are you. You matter to the last moment of your life, and we will do all we can not only to help you die peacefully, but also to live until you die." 


The physician's task as stated by Edward Trudeau many years ago "to cure sometimes, to relieve often, to comfort always" seems to be the basis for care at Hospice. While the health team at Hospice consists of doctors, nurses, clergy­men, social workers, psychiatrists, and volunteers, the most important person is still the physician. Too often the dying client feels abandoned by the doctor, that one has been written off as incurable -- therefore to be ignored as fre­quently as is possible by that one person whom they have come to trust and depend on. The Hospice doctors do not shun their clients or try to avoid "uncomfortable discussions" concerning their illness. The client knows the illness, prog­nosis, and what can be expected in the future. The client is not treated as a child but as an intelligent adult (assuming, of course, the client is an adult). The client is given functions to perform for and by himself for as long as possible. The client is also consulted in regards to the type and amount of pain reducing medication needed, the foods the client wants to eat, and when the client wants to sleep. The physicians sit down with the other members of the health care team on a regular basis to work out a plan of care for the client/family.           

Taking care of the dying client has been part of medical treatment down through the ages. Maybe even now it should n_-It been excluded from the mainstream of medicine, since it has always been the responsibility of compassionate family phy­sicians. Clients welcome continuity of care until their last breath (this is the "rule rather than the exception in Hosp- ice" S. Lack),  This editorial comment of John P. Callan, i•'1.D.~l was refuted a few months later in the same journal by Sylvia A. Lack and William Fischer from the New Haven Hospice. In response, they commented that the ultimate goal of the hospice movement is reincorporation of timeless values and accepted methods into general medical care, and not to exclude the care of the dying from the mainstream of medicine. Technologically specialized curative medicine has catalyzed the growth of the hospice Medical care as a natural balance. Part of our res­ponsibility and commitment is to educate health professionals that a "care system" can coexist with a "cure system". This requires fundamental changes in attitude. Until these ulti­mate goals are realized, hospice care remains the only way to get competent and compassionate terminal medical care from a multidisciplinary team on a continuously available basis for care in the home and for bereavement follow-up.

Most hospices require the primary physician to remain responsible for the client's on-going plan of care. 

Dr. Grebin, St. Mary's Hospice, said that one continu­ing uncertainty was the attitude of the profession and whether medical authorities would be prepared to make referrals. Some physicians "stand back from the idea that they cannot do any­thing" for the dying client, h°_ declared, adding; that it was even more difficult for the physician to accept the fact that he had reached the end-point of treatment for a child. 

            Although the majority of practicing physicians may be­lieve that it is better for them to be reticent with the dying, this opinion must be reconsidered in the light of the fact that an equally large proportion of lay people say that they would like to be told. On the surface, it seems quite per­verse that 80 or 90% of physicians say that they rarely, if ever, tell clients that their illness is mortal (Oken 1961)13 whereas about 80p of clients say they would like to be told (Gilbertsen & Wangensteen, 1961).1 If a physician sees the question in rather unreal black and white terms of either pressing unpleasant news of impending death upon a client or keeping the client in happy ignorance of one's fate, this will sway the physician towards expressing an opinion against tell­ing. This travesties the usual situation, however, where the dying person, with gathering doubts and clues, becomes in­creasingly suspicious that the end is near. 

While physicians are trying to judge their clients' capacity to stand unpleasant news, many clients are equally making their intuitive judgments of whether their physician can bear sincere but difficult questions. (Hinton 1967).15 

"Medicine tries to deny the need for pain, suffering, and death. So when they do appear, their victims, deprived of cultural support, have to face them unprepared. With the belief that the physician's task is to struggle against death, man has lost control over his own destiny. The medical pro­fession has undermined the ability of people to manage their own lives" (Downie 1974).16 

In a 1979 New York Times article, Hugh O'Haire17 stated physicians agree that community-based treatment is not only more convenient but also welcome to clients because of some of the immediate but short-lived side effects of chemotherapy which make travel arduous. According to Dr. Roger Winn, chairman of a community-based outreach program of Memorial Sloan-Kettering Cancer Center, "doctors trained at large city­-based medical centers are now able to carry out complex treatment regimens at the community level.” 

In the    St. Luke's Hospice Pilot Project, the physician’s role is summed up as follows:

1) To see referred clients and decide if they are hospice candidates;

2) To discuss with the client's physician if the client is to be picked up by the Team;

3) To prescribe a plan of care in coordination with the client's physician;

4) To see clients at least once a week and more fre­quently as needed;

5) To discuss the client's condition and plan of care with the Team once a week;

6) To see clients in the clinic;

7) To function as a consultant to other physicians who desire help in managing the symptoms of advanced cancer;

8) To assist with the writing of a research proposal related to the care of clients with advanced carcinoma.


Mindful that not all pain suffered by the cancer client is due to the cancer, the hospice team seeks to control the pain so that it will not return. They strive for constant pain control! The client who experiences pain quickly learns to fear it. Most physicians in most conventional hospitals would prescribe pain relief medications every three to four hours whenever necessary (prn). By the time the client's pain medication arrives, the client is anxious, fearful, and probably angry. It then takes approximately one half hour for the medication to work and become effective, and even longer for the client to calm down. The client may get an hour worth of peace and then the vicious cycle begins again -- anticipa­tion of the expected pain, the wait again, and the short-term relief. 

The Hospice Team tries to avoid the waiting period for terminal clients. The client knows that there will not be a wait for relief-medication is administered in anticipation of the pain. If pain is eliminated, so is the fear of it. One does not become depressed or angry and one is able to derive the maximum relief from the drug given. 

Non-narcotic drugs are used for as long as they are ef­fective for each individual client. When relief is no longer attained, narcotic drugs are given. Fear of addiction is not a concern of the Hospice Team. The nurses will administer the smallest dose possible to accomplish the desired results an alert, pain-free client. Narcotics are usually administered with phenothiazines to potentiate the narcotic, to provide an antiemetic effect, and to alleviate anxiety. 

At the New Haven Hospice, morphine dissolved in cherry syrup and phenothiazine is used for their clients. This is referred to as the "Hospice Mixture". Cocaine, alcohol, or chloroform water (components of the famous Brompton’s Cock­tail) is not deemed necessary. The Hospice staff also considers the use of heroin unnecessary in almost all cases. 

The current debate about whether to permit the use of heroin or morphine by dying clients is symptomatic of a larger problem: the lack of a humane approach to the care of the incurably ill. 

Dr. Robert Butler, Director of the National Institute on Aging, editorialized in 1977 that there are several fac­tors to consider in dealing with the pain that characterizes the final days for many. Physicians must change their pre­sent practice of prescribing analgesics "as needed" and be­gin to prescribe small doses of effective painkillers, gradually increasing the dose until the client is p  infree. The next dose should be given before the client may even think it is necessary. Thus, it is possible to erase both the memory and the fear of pain and to enable the client to review life and face death as serenely and comfortably as possible. Relief from pain is essential, and physicians should be able to prescribe the most effective drugs for their clients, including morphine and heroin. 

With the current system of waiting for pain relief, clients actually require a higher dosage of medication than would ordinarily be indicated. With lower dosages required clients experienced less confusion and were afforded more "quality time" to talk and share feelings with friends and loved ones. 

In another New York Times editorial by Harold M. Schmeck, Jr., it was suggested that the person dying of cancer usually needs protection from pain and fear. The treatment for pain and nausea is sometimes so cautious as to suggest that those in charge consider it either unimportant or immoral to deal thoroughly with the client's final agony. 

The attitude appears to be changing, however; and the change was accelerated recently by the prodding of no less an agency that the White House. 

The current focus is on two drug-- heroin and marijuana. The current attitude seems to be toward making these drugs more easily available, at least through legitimate research projects with clients. How far this will go and soon is not yet clear. 

Heroin proved to be no more effective than morphine when administered orally at St. Christopher's Hospice as part of the Brompton mixture, a cocktail of narcotics, tranquilizers and alcohol given regularly to terminal cancer clients (Clark 1978).22 

THC, the active ingredient in pot (marijuana) was tried as an antiemetic on a small group of clients receiving chemo­ therapy and found no better than conventional anti-nausea drugs. Dr. Peter Bourne, a President's special assistant health issues and an expert on narcotic abuse, and other experts believe ­that questions about the usefulness of heroin and marijuana can be resolved within the next few years. 

The hospice at St. Luke's Hospital Center, New York City controls severe pain with methadone by mouth, giving it in initial doses of 5-10 mg. At 3-4 hour intervals. They have also had good results controlling pain with an oral solution consisting of morphine sulfate, 15 mg; cocaine hydrochloride, 10 mg. 951% alcohol, 1.7 ml. cherry syrup, 3.7 ml. and distilled water, 10 ml. It is given to many clients around the clock instead of prn (whenever necessary) because of the chronicity of their pain. Pain that is not allowed to reach peak intensity is easier to control.

 Tylenol or aspirin sometimes is given with narcotics (though not all clients require narcotics) to potentiate their effects. Some clients require only APL's with codeine. 

Analgesics may not always be needed to treat discomfort. What is essential is an assessment of the pain -- noting its site, duration, pattern, precipitating factors, and what relieves it.


Nursing; students expressing an interest in thanatology can refer to professional journal articles, as well as register for elective courses in "Death and Dying" at their affiliated colleges. Some of the classic nursing and medi­cal articles, books, workshops, and forum papers are listed in the Bibliography. It is impossible, of course, to list every article or book ever written on the hospice Movement or on '' Death and Dying. However, a fairly good resource list has been compiled for your use. 

For the graduate nurse the same opportunities exist as for the future nurses still in schools and colleges. The opportunity for further education in this contemporary field can also be found in the many in-service education programs/ workshops/conferences offered by their employers. 

A copy of in-service education programs and workshops open to all nurses that are offered by various institutions in the New York area can be obtained by writing to the in­stitutions directly. Speakers and sources of very pertinent in formation on thanatology and the hospice movement are not only diversified but also follow a much dispersed geographi­cal pattern. 

St. Vincent's hospital in Manhattan gave a pre-test/ personal questionnaire on one's perspectives on dying before beginning a workshop on the "Care of the Dying Client." It was a very enlightening experience for the participants. This particular workshop provided time for peer sharing and discussing of one's views on the subject. This was found to be a most beneficial aspect of the workshop by the many parti­cipants. 

Continuing education in nursing, a future must, also provides the opportunity for educational advancement in the area of thanatology. Many community colleges, senior col­leges, and hospitals offer C.E.U.'s (continuing education units) for the courses they present during the day, evening, or weekends.

 Some institutions offer conferences on various topics such as hospice, or provide paid "professional leave days" for their nurses to attend conferences in other institutions. 

Thus, nursing professionals have various opportunities to learn about, discuss, and update their professional and personal knowledge and skills.



1. Elisabeth Kubler-Ross, On Death and Dying (New York, 1969). 

2. Leonard A. Liegner, "St. Christopher's Hospice, 1974," JAMA, 234:10 (December 8, 1975), 1048. 

3. Cicely Saunders, "The Management of Terminal Illness," Hospital Publications, Ltd. (1967). 

4. Sylvia A. Lack, "Philosophy and Organization of a Hospice Program," at the First National Training Conference for Physicians on Psychosocial Care of the Dying Patient (April 29 - May 1, 1976). 

5. Vincent J. Dunigan, "Where the Dying Come to Live," The Catholic Digest (May, 1980), 89-92. 

6. Sandol Stoddard, The Hospice Movement - A Better Way of Caring for the Dying (New York, 1978), p. 222. 

7. Robert Lowell, in "Living With Dying," in Newsweek, Kenneth L. Woodward, Mariana Gosnell and others (May 1, 1978). 

8. Jane L. Hoskovec, "Hospice - An Alternative Method of Care," St. Mary's Messenger (Spring, 1980), 21. 

9. Stoddard, p. 120. 

10. Sylvia A. Lack and William Fischer, "The Hospice Movement," JAMA, 241:24 (June 15, 1979). 

11. John P. Callan, "The Hospice Movement," JAMA 241:6 (February 9, 1979). 

12. Kathleen Teltsch, "Young Terminal Patients to Get a Loving Hospice," The New York Times, April 10, 1980­ 

13. D. Oken, "What To Tell Cancer Patients," JAMA 1:20 (1961), 175. 

14. V. A. Gilbertsen and 0. H. Wangensteen, "Should the Doctor Tell The Patient That The Disease Is Cancer?," in The Physician and the Total Care of the Cancer Patient, New York, American Cancer Society (1961). 

15. John Hinton, Dying (New York, 1967). Reprinted: John Hinton, "Speaking of Death With the Dying," in Death: Current perspectives, ed. Edwin S. Shneidman (Ca, 1976), 303-31 

16. Patricia N. Downie, "A Personal Commentary on the Care of the Dying on the North American Continent," Nursing Mirror (October 10, 1974), 161-166. 

17.       Hugh O"Haire,  "Fighting Cancer:          Therapy Is Closer? O Home," The New York Times, December 9, 1979, p. 6. 

18. Ibid. 

19. Hospice Pilot project, St. Luke's Hospital Center (New York, 1975), p.8. 

20. Robert Butler, "To Remove a Dying Patient's Pain," The New York Times, December 2, 1977. 

21. Harold M. Schmeck, Jr., "Addictive Drugs as a Way of Eas­ing Death," The New York Times, November 27, 1977. 

22. Matt Clark, Dan Shapiro and Diane Camper, "A Fix for Pain," Newsweek (January 2, 1976), 41.



New York City 

Calvary Hospital
Bronx, New York 

St. Luke’s – Roosevelt Hospital Center
New York,
New York 

The Brooklyn Hospice
The Metropolitan Jewish
Geriatric Center
Brooklyn, New York 

St. Mary’s Hospital
Bayside, New York 

North Shore University Hospital
Manhasset, New York 

Memorial Sloane-Kettering Cancer Center
New York,
New York 

Mercy Hospital Hospice
Rockville Centre, New York 

Long Island Jewish-Hillside Medical Center
New Hyde Park, New York


New York State 

United Hospital
Port Chester, New York 

Mercy Hospital Hospice
Rockville Centre, New York 

Long Island Jewish-Hillside Medical Center
New Hyde Park, New York 

Hospice Care, Inc.
New Hartford, New York 

Our Lady of Lourdes Hospital
Binghamton, New York 

Planning and Educational
Foundation of Westchester, Inc.
White Plains, New York




I. The aim of all therapy is relief of uncomfortable and unpleasant symptoms in all areas.


   The proper dose of any medication is the effective dose for the individual patient.




II. Aim to keep the patient both free of pain and fully alert.




1. Chronic pain demands preventive therapy, which means that analgesics should be given regularly and prophylactically.


2. The right dose is that which gives relief for a reasonable period of time: a four-hourly interval may be regarded as the norm between administrations.


3. Non-narcotic analgesics should be tried in the first instance.


4. If ineffective - transfer to a stronger preparation.


5. Adjuvant medication is the rule rather than the exception. A phenothiazine such as prochlorperazine or chlorpromazine acts as an antiemetic and, pos­sibly, potentiates analgesia.


6. Use oral medication whenever possible - it is easier to administer and does not necessitate in­patient treatment.

7. There is more to analgesia than analgesics. Some pain responds better to other forms of treat­ment, e.g., radiotherapy, cytotoxic drugs, nerve blocks, alone or in combination with analgesics.


8. Diversional therapy. The perception of pain re­quires both attention and consciousness. Diversional therapy - people to talk to, activities to attend, etc. - is, therefore, of great value. 

9. Morphine, Methadone, and Dilaudid.

The use of these drugs does not guarantee success, particularly if the psychological component of pain is ignored.


  • Mild Pain
    Ascaf Tylenol for those intolerant of aspirin 

Moderate Pain

  • ASA with codeine o/015 gm. Percodan

  • Talwin

  • (with or without compazine or thorazine syrup or tablet) 

Severe Pain

Thorazine, Phenergan or Compazine tablet or syrup with:

  • Methadone

  • Dilaudid

  • Morphine 


  • Rhubarb and soda

Steroids: Prednisone, Dexamethasone 

Nausea and Vomiting

  • Tigan

  • Compazine

  • Thorazine

  • Phenergan 


l) Bronchodilators
            Aminophylline suppository

2) Steroids

3) Antibiotics (if infection is prominent feature) 

4) Opiates

5) Terminally only, when dryness will not be apparent to     patient – atropine


  • ETH with codeine
    Benylin expectorant
    Glyceryl guaiacolate

Anxiety, Mental Distress

  • Valium, P.O., I.V.

  • Thorazine

  • Haldol

  • Stelazine 


  • Thorazine P.O., I. M.

  • Haldol with or without Artane 


1) Attention to physical and mental distress 

2) Steroids if indicated 

3) Antidepressants:

  • Elavil

  • Tofranil

  • Ritalin


  • Chloral hydrate

  • Phenergan

  • Valium

  • Dalmane

  • Elavil 


  • Colace

  • Senokot
    Dulcolax tablets or suppository
    Cascara, with or without milk of magnesia Enema 

Fungating Growths

1)         Clean with peroxide
2)         Bacitracin ointment
3)         Non-adhesive dressing

Frequency of Urination

1) Treatment of infection according to results of culture

2) Pyridium


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