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Changing attitudes means getting more people to give up rescue medicine in favor of comfort care when the hope of a cure is minuscule. "For many people, it's easier to say, 'Whatever you say, Doc,' rather than spend two weeks thinking through your own death," says Lynn. "That's uncomfortable. But life is mostly about grandchildren and gardening, sunrises and eating chocolate. It's not about pills." Fine, but how do you eat a Hershey bar when you know it could be your last?
One solution is hospice, a kind of care for the dying that emphasizes comfort over cure. Hospice patients must forgo further curative and life-prolonging treatments, which means they usually leave the hospital. (A hospice can be a separate place, but usually the word refers to home care.) Doctors, social workers, art therapists and others manage physical pain and help patients navigate the emotional terrain of dying.
When John Wracian, 80, was first diagnosed with colon cancer last year, the former General Motors supervisor from Downey, Calif., underwent surgery. But when it didn't work, he accepted that chemotherapy probably wouldn't either. Instead, a hospice nurse checked on him and his wife Carol twice a week, as did a chaplain. "It's the best thing that came along," said John, who read several books a week and watched the Dodgers. "Nine days in the hospital [for surgery] was more than enough. Now I'm home, enjoying the life I have." He and Carol didn't expend energy on frequent trips to doctors; instead, the couple focused on saying goodbye. "When the time comes and he's gone, I won't have to look back and say, 'I wish I would have said that,'" said Carol, recalling that her dad passed away without ever speaking with her mother about his dying. John Wracian died Sept. 2.
Hospice can also have more practical benefits. "We discuss whether they need a homemaker to wash dishes or read to the patient so his wife can get out because she's exhausted," says Margaret Clausen, president of the California Hospice Foundation. On average, hospice patients receive at least three hours a day more attention than nursing-home patients. And hospice is cheaper than traditional care. For example, at Balm of Gilead Center, a hospice in Birmingham, Ala., the average cost per patient per day is $720, in contrast to $3,180 for ICU patients.
But hospice, which well-meaning clergy members imported to this country from Britain in the 1970s, ministers to only 17% of dying Americans. "The word hospice has toxic connotations," says Clausen. That's partly because Medicare starts a fatal clock ticking on hospice patients: it will reimburse for hospice only after two doctors certify that a patient has less than six months to live. But many doctors are reluctant to do so, especially for unpredictable diseases like heart failure. Some physicians also fear regulatory scrutiny, since the U.S. Health Care Financing Administration has actually ordered investigations of hospice patients who live longer than six months. Some fear that a short prognosis will be self-fulfilling, and many just don't like to tell someone he is dying. Hence the average length of stay in U.S. hospices is between two and three weeks, hardly enough time to take advantage of a hospice's supportive environment.