MORTALITY, MORALITY & HONOR:
THE END-OF-LIFE PARADIGM
DA VINCI’S VITRUVIAN MAN - 1490
VITRUVIUS 25 B.C.
THE CIRCLE REPRESENTS THE
COSMIC & THE DIVINE
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THE SQUARE, THE EARTHLY
& THE SECULAR
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THE GOAL: LINEAR TO CIRCULAR
THE LONG FLAT TABLE
NO
LONGER
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ANOTHER “DR DEATH ?”
MY MANTRA
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GROW OLDER & DIE YOUNG
AS LATE AS POSSIBLE
PLAN ON IT
PLAN FOR IT
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AND MY WISH?
TO WRITE MY LAST
CHAPTER…. AND
WHEN
IT IS READ, A LONG
TIME
FROM NOW, HAVE IT
BE RECOGNIZED AS A
WORK OF NONFICTION
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A CONSTANT ?
OR AN EVER-CHANGING LANDSCAPE ?
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IF YOU WANT TO HIT A BIRD ON
THE WING YOU MUST HAVE YOUR
MIND IN FOCUS. YOU MUST HAVE
THAT BIRD IN YOUR MIND’S EYE.
EVERY GREAT ACHIEVEMENT IS A
BIRD ON THE WING.
OLIVER WENDELL HOLMES Jr
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IF YOU A WANT “BEST” READ
A “MUST” READ
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ATUL GAWANDE
MD
“LETTING GO”
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NEW YORKER
AUG 12, 2010
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WHY NOW ? WHY HERE ?
A BIG ISSUE
A DIVISIVE ISSUE
A “CIVIL” RIGHTS
BATTLE
What Percent of People Will
Eventually Die?
AND IT WON’T BE EASY
GALLUP’S VALUES AND
BELIEFS POLL - MAY ‘10
DWD - PAS
45 % - IT’S MORALLY
ACCEPTABLE
32 % - IT’S MORALLY
WRONG
“IT”
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THE RIGHT, IN
ADULTS
OF SOUND MIND, TO
EXERCISE CHOICE
AND
CONTROL FOR THEMSELVES AT THE END
OF
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DOES THIS MAKE A DIFFERENCE ?
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NATIONWIDE, RECENT POLLS
SHOW THAT >70% OF AMERICANS BELIEVE THAT TERMINALLY
PATIENTS SHOULD HAVE
THE RIGHT TO SELF-ADMINISTER
A LETHAL MEDICATION TO
ACHIEVE A PEACEFUL DEATH.
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I KNOW- POLLS !
‘05 GALLUP
75% SAID YES TO DOCTORS
BEING ALLOWED TO HELP THE
TERMINALLY ILL DIE
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BUT ONLY 58% SAID YES WHEN
THE WORD
INCLUDED
SUICIDE
WAS
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BUT INCREASINGLY
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THE COURTS AND THE PUBLIC
RECOGNIZE THAT TERMINALLY ILL
PATIENTS ASKING FOR AID IN DYING
ARE NOT “SUICIDAL”
AND PROVIDING SUPPORT IS NOT
“ASSISTING SUICIDE.”
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SO WHO IS AGAINST
PHYSICIAN ASSISTED DEATH ?
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THREE BROAD CATEGORIES:
SANCTITY OF LIFE MUST BE PRESERVED
THE SLIPPERY SLOPE MUST BE PREVENTED
THE MEDICAL SYSTEM CAN ELIMINATE OR
ALLEVIATE END-OF-LIFE SUFFERING
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WITH ALL DUE RESPECT
U.S. CONFERENCE OF BISHOPS –‘11
“ALL PATIENTS – INCLUDING THOSE
IN THE SO-CALLED PERSISTENT VEGETATIVE STATE – BE PROVIDED WITH
ARTIFICIAL HYDRATION AND NUTRITION
IF SUCH CARE COULD EXTEND LIFE, EVEN
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INDEFINITELY.”
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CATHOLIC ETHICAL & RELIGIOUS
DIRECTIVES – (CERD’s)
“VIRTUE IS PROTECTING & PROLONGING LIFE, OVER ALL VIRTUES,
OVERRULING PATIENT CONCERNS
ABOUT THEIR QUALITY OF LIFE.”
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“PATIENTS EXPERIENCING SUFFERING THAT CANNOT BE ALLEVIATED
SHOULD BE HELPED TO APPRECIATE
THE CHRISTIAN UNDERSTANDING OF
REDEMPTIVE SUFFERING.”
IRONY TO ANXIETY: 40 % OF HOSPITALS……
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THE HIPPOCRATIC OATH
ORIGINAL ENGLISH TRANSLATION:
“I WILL NOT GIVE A LETHAL
DRUG TO ANYONE IF I AM ASKED”
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MODERN TRANSLATION:
“I WILL REMEMBER THAT THERE IS
AN ART TO MEDICINE AS WELL AS
SCIENCE, AND THAT WARMTH, SYMPATHY AND UNDERSTANDING MAY
OUTWEIGH THE SURGEON’S KNIFE
OR CHEMIST’S DRUG”
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THE MANTRA – THE MYTH
DOES PAD, (DWD), CONTRADICT A PHYSICIAN’S RESPONSIBILITY TO PRESERVE
LIFE?
COMPASSION:
THE HUMANE QUALITY OF UNDERSTANDING THE SUFFERING OF
OTHERS AND THE DESIRE TO DO
SOMETHING ABOUT IT
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IRONY
WHAT WOULD HAPPEN IF THERE WERE NO MORE DEATH ?
WE WOULD HAVE NO NEED FOR
PROGRESS OR ART, FAITH OR FAME
WE WOULD HAVE LITTLE TO DO
YET IN THE GREATEST OF IRONIES,
HAVE ENDLESS EONS IN WHICH TO
DO IT.
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ACTION WOULD LOSE IT’S PURPOSE,
TIME ITS VALUE
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THE “SLIPPERY SLOPE”
WILL ADVANTAGE BE TAKEN
NO, ABSOLUTELY NOT!
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RATES OF ASSISTANCE IN STATES,
COUNTRIES), WHERE DWD IS LEGAL
HOW ABSOLUTELY NO BIAS AGAINST
HE
HE
HE
HE
HE
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ELDERLY
UNINSURED
UNEDUCATED
MINORITIES
POOR
REVERSE SLOPE ?
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THE W & W - THE D & A
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AND AS FOR COMPLETE RELIEF
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LET US ASK WHY PALLIATIVE
CARE HAS EMERGED AS A
RESPECTED & ESSENTIAL PART
OF OUR MEDICAL LANDSCAPE ONLY RECENTLY !
COLORADO SB 102 - 2006
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PAIN & COMPASSION
(PLEASE REFLECT ON IT)
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WHAT ARE WE GOOD AT ?
OUR MEDICAL SYSTEM IS
EXCELLENT AT TRYING TO
STAVE OFF DEATH WITH:
ICU CARE $5,OOO+/DAY
CHEMOTHERAPY $8,OOO/MO
SURGERY $5,000/HR
BUT ULTIMATELY, THE
OWL CALLS OUR NAMES
AND NOT SO GOOD AT ?
“AGAINST OTHER THINGS IT IS
POSSIBLE TO GAIN SECURITY, BUT
WHEN IT COMES TO DEATH WE
HUMAN BEINGS ALL LIVE IN AN
UNWALLED CITY.”
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“NO ONE WANTS TO DIE. EVEN
PEOPLE WHO WANT TO GO TO
HEAVEN DON’T WANT TO DIE TO
GET THERE. YET DEATH IS THE
DESTINATION WE ALL SHARE.”
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AND DOES OUR MEDICAL PROFESSION
HAVE A PROBLEM WITH THIS ?
JENNIFER TEMEL MD – MGH
NEJM 2010
(RANDOM ASSIGNMENT OF 151 ADV LUNG CANCER PTS TO “REGULAR CARE
OR CARE & EARLY DISCUSSIONS WITH PALLIATIVE CARE
GROUP TWO:
BETTER QUALIITY OF LIFE & LESS TROUBLESOME SYMPTOMS IN TIME REMAINING
PHYSICIANS SHOWED A BETTER APPRECIATION OF PT’S WISHES & WERE MORE
LIKELY TO RECOMMEND CARE CONGRUENT WITH THOSE WISHES
FAMILIES SHOWED LESS GUILT & DEPRESSION AFTER THE DEATH.
GROUP TWO LIVED A LITTLE LONGER TOO (2.7M)
MORE ? - THE KEATING STUDY
(CANCER 15 2010)
NANCY L KEATING MD, MPH
HARVARD MEDICAL SCHOOL
BY QUESTIONAIRRE, (4,000+ PHYSICIANS CARING
FOR CANCER PATIENTS
LOOKED AT TIMING OF DISCUSSIONS ON
1. ACCURATE PROGNOSIS
2.WISH FOR “DNR”
3. NEED FOR HOSPICE
4. PREFERRED SITE OF DEATH
CONCLUSIONS:
MOST PHYSICIANS REPORT THEY WOULD NOT
DISCUSS END-OF-LIFE OPTIONS WITH
TERMINALLY ILL PATIENTS WHO ARE FEELING
WELL.
“THERE WILL BE TIME FOR THAT LATER.”
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A DOUBLE STANDARD ?
“WHY DOCTORS DIE
DIFFERENTLY”
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KEN MURRAY
CAP - FAMILY
MEDICINE
UNIV SO CAL
WSJ 3/10/12
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HONESTY – THE BEST POLICY ?
HEALTH AFFAIRS
JOURNAL
FEB, 2012
POLL OF 2000 MD’s
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MORE THAN HALF HAD
FRAMED A PROGNOSIS
IN
A MORE POSITIVE
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SIGNS OF CHANGE ?
2011 SURVEY BY THE REGENCE
FOUNDATION ON BEHALF OF THE
NATIONAL JOURNAL FOUND
THE 96% OF MD’s BELIEVE IT’S
MORE IMPORTANT TO IMPROVE
PATIENT’S QUALITY OF LIFE
THAN
TO PROLONG THEIR LIVES.
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79% OF MD’s SURVEYED SAID:
“U.S. SPENDS FAR TOO MUCH
TRYING TO EXTEND LIVES”
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ALZHEIMER’S DISEASE
“A DEGENERATIVE DISEASE THAT
IS 100% INCURABLE AND 100% FATAL,
WHICH ROBS ITS VICTIMS OF MEMORY,
JUDGEMENT & DIGNITY, LEAVING THEM
UNABLE TO CARE FOR THEMSELVES,
AND DESTROYING THEIR BRAIN AND
THEIR DIGNITY, OFTEN DEPLETING
THE RESOURCES OF THEIR CAREGIVERS
AND THEIR FAMILIES – BOTH EMOTIONALLY & FINANCIALLY.
JUSTICE SANDRA DAY O’CONNOR
OCTOBER 27TH, 2010 NY TIMES
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AND A SOBERING THOUGHT
STARTING ON JAN 1, OUR 79 MILLION
STRONG BABY BOOM GENERATION
WILL BE TURNING 65 AT THE RATE OF
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1 EVERY 8 SECONDS !
AND THE REALITY IS THAT THE
INCIDENCE OF DEMENTIA DOUBLES
EVERY FIVE YEARS AFTER 65
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KAREN KEHL – Am J Hosp & PC
“MOVING TOWARD PEACE”
A GOOD DEATH
BEING COMFORTABLE
BEING IN CONTROL
HAVING A SENSE OF CLOSURE
MAKING MOST OF RELATIONSHIPS
HAVING FAMILY INVOLVED
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IN WHICH IS THERE TIME FOR…
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MORTALITY, MORALITY & HONOR
CHOICES AT THE END OF LIFE
THE SEMINAL CASE
KAREN ANN QUINLAN - 1976
CHRONIC VEGATATIVE STATE
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PARENTS REQUEST “WITHDRAWAL”
NJ SUPREME COURT RULES IN FAVOR
OF THE “RIGHT TO REFUSE ARTIFICIAL
VENTILATION”
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KAREN ANN QUINLAN - 1954-1985
THE FATHER, A FIRM CATHOLIC,
AND THE ASSIGNED GUARDIAN,
WAS A POSITVE FORCE IN THIS
CASE, FOR ADDRESSING HIS
CONSCIENCE AND MOTIVATIONS
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THE FIRST CASE ABOUT THEOLOGY,
BIOETHICS, EUTHANASIA, LEGAL
GUARDIANSHIP AND CIVIL RIGHTS
POSITIVES: BIOETHICS COMMITTEES
ADVANCE DIRECTIVES
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TERRI SHAIVO – CVS – 1990-’05
ESSENTIALLY, A TRAGEDY:
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OF PERSONAL LIVES
OF THE LAW
OF POLITICS
ULTIMATELY, AN EMBARRASSMENT
( READ “USING TERRI”)
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‘87, ’89, ’91: OREGON WRITES
LEGISLATION GRANTING
INDIVIDUAL OPTIONS FOR ENDOF-LIFE (SS FRANK ROBERTS)
NO BILL LEAVES COMMITTEE
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THE HISTORY OF END-OF-LIFE
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CHOICES IN THE UNITED
ROBERTS DIES A HARSH DEATH
AT HOME AT LEAST – OCT ‘93
‘94 OREGON PASSES VOTER INITIATIVE
TO ALLOW DWD (51 TO 49 %)
(SIGNED INTO LAW BY ROBERT’S WIFE
& GOVERNOR, BARBARA ROBERTS)
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INTERCONNECTIONS
APRIL, ‘93, AT THE PEAK OF THE AIDS EPIDEMIC, ACTIVISTS ESTABLISH “COMPASSION IN DYING” IN SEATTLE, WASHINGTON, PUBLICALLY DECLARING THEIR INTENTION TO COUNSEL MENTALLY
COMPETENT, TERMINALLY ILL PATIENTS ON AID-IN-DYING.
PUBLISHED WERE SPECIFIC ELIGIBILITY CRITERIA, GUIDELINES AND
SAFEGUARDS AND VOLUNTEERS TO ATTEND DEATH.
A MEDICAL MODEL EVOLVES WITH CLIENT ASSESSMENT, PROFESSIONAL REFERRALS, AN INTERDISCIPLINARY TEAM OF VOLUNTEERS
AND SELF-ADMINISTERED MEDICATION.
JUNE, 1997
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“THROUGHOUT
THE NATION,
AMERICANS Fourth
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ARE ENGAGED IN Fifth
AN EARNEST AND PROOutline
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FOUND DEBATE ABOUT
THE MORALITY,
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SICIAN AID IN DYING.
OUR HOLDING
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PERMITS THIS DEBATE
TO CONTINUE,
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AS IT SHOULD IN
A DEMOCRATIC
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SOCIETY.”
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Facts on Use of Oregon Law
Median Age 70 (25-96)
White - 97.5%
Sex - 53.1% Male - 46.9% Female
Education - 67% had attended college
Suffering from cancer - 81.8%
Enrolled in hospice - 87.8%
Insurance - 98.2%
94% died at home
OREGON AT 14 YEARS
I CONTEND NO
“SLIPPERY SLOPE”
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BUT AN AGING POPULATION
WITH MORE CHRONIC DISEASE
AND
MORE KNOWLEDGE
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“REASONS FOR ‘CHOICE’”
LOSING AUTONOMY
CANNOT ENGAGE IN
PLEASURABLE ACTIVITIES
89.9 %
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87.4 %
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LOSING CONTROL OF BODILY
FUNCTIONS
58.7 %
BURDEN TO FRIENDS
INADEQUATE PAIN CONTROL
39.3 %
23.9 %
FINANCIAL CONSIDERATIONS 2.8 %
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THE “HOW TO”
A TERMINALLY ILL, COGNITIVELY  Click to edit the
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LETHAL DOSE OF MEDICINE, PROVIDED
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THE PATIENT:
Level
1.
2.
3.
4.
HAS BEEN ADVISED OF OTHER OPTIONS
HAS MADE TWO VERBAL APPEALS / 15D
HAS MADE A WRITTEN REQUEST
WITNESSED BY TWO WHO ARE NOT
CARETAKERS OR FAMILY
5. ORAL, NOT IV MEDS / HELIUM
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OUR GOVERNMENT IN MEDICINE
OBAMA CARE & “DEATH PANELS”
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FROM AN OFTEN CITED PROVISION
OF THE UNPASSED BILL WHICH WOULD
HAVE AUTHORIZED MEDICARE REIMBURSEMENT FOR PHYSICIANS WHO
WOULD PROVIDE VOLUNTARY COUNSELING ABOUT SUCH SUBJECTS AS
PATIENT & FAMILY WISHES, LIVING
WILLS,
AD’s…………..CHOICES……..
AT THE END OF LIFE
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AH…. WHAT TO MAKE OF IT
BETSEY McCOUGHEY
VP CANDIDATE PALIN
“MY PARENTS & MY BABY WITH
DOWN’S SYNDROME WILL HAVE TO
STAND IN FRONT OF OBAMA’S DEATH
PANAL SO BORED BUREAUCRATS CAN
DECIDE, BASED ON SUBJECTIVE
JUDGEMENT, ON THEIR ‘LEVEL OF
PRODUCTIVITY IN SOCIETY’, WHETHER
THEY ARE WORTHY OF HEALTH CARE.”
“NULLIUS IN VERBA”
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THE FALLOUT
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STUDIES SHOWED THAT
30 TO 45 % OF AMERICANS
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BELIEVED THIS RHETORIC
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MORE GOVERNMENT
JANUARY 1, 2012 – CREATION
OF “INDEPENDENCE AT HOME
ORGANIZATIONS” – GROUPS OF
DOCTORS & NURSES TO Rx PTS
AT HOME & INCENTIVES TO
MAKE THAT WORK APPEALING.
PAID FOR BY SAVINGS FROM
DIMINISHING HOSPITAL STAYS
AND PROCEDURES
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AND AGAIN ?
IN THE AHCA, IN 2014,
THE INDEPENDENT PAYMENT
ADVISORY BOARD, (IPAB),
MAKES RECOMMENDATIONS
ON COST SAVINGS, YET IS
EXPRESSLY PROHIBITED FROM
TAKING ANY ACTION WHICH
WOULD RATION CARE.
BUT…………..
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AN INTERESTING POLL
FIFTY-THREE % OF AMERICANS
WOULD JUST AS SOON SEE THE
HEALTH CARE BILL REPEALED.
FORTY-THREE % SUPPORT IT.
OF INTEREST, 70% OF THE
53% OPPOSED, FAVOR 2/3
OF THE BULLETS CONTAINED
IN THE BILL.
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THERE’S AN ARGUMENT
ANY CENTRALLY ADMINISTERED
HEALTH-CARE SYSTEM WILL, INEVITABLY,
MAKE “COST-MINDED JUDGEMENTS ABOUT
WHAT TYPES OF CARE” SHOULD BE PROVIDED TO WHICH CATEGORIES OF PATIENT
ALREADY HAPPENING
ARIZONA: THE STATE CUT OFF REIMBURSEMENTS FOR ORGAN-TRANSPLANTS FOR THE POOR
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NEVER TALK ABOUT THE COST
(BUT BE REMINDED)
25 %OF ALL MEDICARE SPENDING
IS FOR THE 5 %OF PATIENTS WHO
ARE IN THE FINAL YEAR OF LIFE, AND
MOST OF THAT MONEY GOES FOR
CARE IN THEIR LAST MONTHS OF
LIFE WITH LITTLE BENEFIT IN TERMS
OF LONGEVITY OR QUALITY OF LIFE.
(ABOUT 60 BILLION)
AND THE PSYCHOLOGICAL,
PHYSICAL AND FISCAL COST TO
FAMILIES ?
OF COURSE, WE DON’T KNOW IT’S THE LAST MONTHS
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CURRENTLY THE LEGAL RIGHT OF
EVERY CITIZEN IN EVERY STATE
A COMPETENT ADULT PATIENT
HAS THE RIGHT TO REFUSE UNWANTED MEDICAL TREATMENT
THAT COULD INCLUDE DIALYSIS,
SURGERY, BLOOD TRANSFUSIONS,
ANTIBIOTICS AND ARTIFICIAL LIFE
SUPPORT, EVEN WHEN REFUSAL
MIGHT LEAD TO DEATH.
THIS RIGHT EXISTS EVEN IF THE
PATIENT IS NOT TERMINALLY ILL.
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WHAT ABOUT OUR CITIZENRY ?
“DO YOU APPROVE OR
DISAPPROVE OF LAWS
THAT LET PATIENTS
DECIDE ABOUT BEING
KEPT ALIVE THROUGH
MEDICAL TREATMENT?”
84% APPROVE
PEW RESEARCH CENTER ’01-’05
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WHO’S SIDE ARE YOU ON?
(IS IT NOT PART OF OUR LEGAL DNA?)
“THE ROOT PREMISE IS THE CONCEPT,
FUNDAMENTAL IN THE AMERICAN
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JURISPRUDENCE SYSTEM THAT EVERY
HUMAN BEING OF ADULT YEARS AND
SOUND MIND HAS A RIGHT TO
DETERMINE WHAT SHALL BE DONE
WITH HIS OWN BODY.”
JUSTICE BENJAMIN CARDOZO
NY COURT OF APPEALS 1914
(US SUPREME COURT 1932-38)
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A DEVIL’S ADVOCATE – MAY I ?
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A FEW THOUGHTS
ON
END-OF-LIFE
PLANNING
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STEPHEN JAY GOULD
BROOKLYN/HARVARD PALEONTOLOGIST
‘85 ESSAY:« THE MEDIAN & THE
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Dx; ABDOM MESOTHELIOMA - ‘85
THE LITERATURE: BRUTAL (8MO’s)
BUT THE CURVE BEYOND THE MEDIAN
WITH A LONG, ALBEIT, SLENDER TAIL
INTERESTED GOULD
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GOULD GETS SURGERY & CHEMO -
AND TWENTY YEARS – D ‘02
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A NATURALIST SPEAKS
“IT HAS BECOME, IN MY VIEW, A BIT TOO TRENDY TO REGARD
ACCEPTANCE OF DEATH AS SOMETHING TANTAMOUNT TO INTRINSIC
DUTY. OF COURSE I AGREE WITH THE PREACHER IN ECCLESIASTES
THAT THERE IS A TIME TO LIVE AND A TIME TO DIE, AND WHEN MY
SKEIN RUNS OUT I HOPE TO FACE THE END CALMLY AND IN MY OWN
WAY. FOR MOST SITUATIONS, THOUGH, I PREFER THE MARTIAL
VIEW THAT DEATH IS THE ULTIMATE ENEMY AND I FIND NOTHING
REPROACHABLE IN THOSE WHO ‘RAGE MIGHTILY AGAINST THE
DYING OF THE LIGHT.’”
STEPHEN JAY GOULD 1985
SO WHAT IS IT WE REALLY WANT
SIMPLY, NOTHING
MORE
THAN YOU WANT
CHOICE AND
CONTROL
AT THE END!
HENCE:
ADVANCE
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AD’S & THE ULLYSES PACT
A FREELY MADE DECISION THAT
IS INTENDED TO BIND ONESELF
IN THE FUTURE
IN MEDICINE, WITH AD’s & LW’s,
THERE EXISTS CONTROVERSY
OVER WHETHER DECISIONS MADE
BY ONE IN ONE STATE OF HEALTH
CAN BIND ONE IN ANOTHER
WHEN AM “I” NOT “ME” ?
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COMPASSION & CHOICES
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WHO WE ARE AND
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WHY YOU SHOULD
GET TO KNOW US
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ABOUT US
Compassion & Choices is the oldest and
largest nonprofit organization advocating for
comprehensive end-of-life care and
treatment options. Founded in 1980 as the
Hemlock Society, and merged with
Compassion in Dying in 2004, over the years
the organization has grown, become more
mainstream and now focuses on improving
care and expanding choice at the end of life.
A YOUNG ORGANIZATION –
WITH TIMELESS CHALLANGES
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1980 – HEMLOCK SOCIETY
2003 – FOUNDER, DH, LEAVES
TO FORM “FINAL EXIT”
2004 – “COMPASSION & CHOICES”
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Eligibility for Services
Clients need not be members
Clients need not be
“terminally ill”
Services may include
referral to other specialists,
organizations, or officials
We never charge for
services
DYING USED TO BE ACCOMPANIED
BY A PRESCRIBED SET OF CUSTOMS
REAFFIRM ONE’S FAITH
REPENT ONE’S SINS
LET GO OF WORDLY AFFAIRS
LAST WORDS
AND A COMFORT TO ALL A WORD ABOUT HOSPICE
BRITISH MD – DAME CICELY SAUNDERS
1940’S ST. CHRISTOPER’S –
LONDON
1964 YALE SCHOOL OF NURSING
THE CONNECTICUTT HOSPICE
1974
“WE DO NOT HAVE TO CURE TO HEAL”
US MD – ELISABETH KUBLER-ROSS
“ON DEATH AND DYING”
FIVE STAGES OF GRIEF
“IT HAS BROUGHT DEATH OUT OF THE DARKNESS”
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HOSPICE - A COMFORT TO ALL ?
MEDICARE COSTS FOR HOSPICE
HAVE INCREASED MORE THAN IN
ANY OTHER HEALTH CARE
SECTOR ‘05 TO ‘10 – 70% !!
IN 2010, 42% OF DEATHS
OCCURRED IN HOSPICES
(22% IN ICU’s)
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MEDICARE PAYS FOR 84% OF ALL
HOSPICE PATIENTS (<6 MOS & ACCEPTANCE)
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“AMERICAN” HOSPICE
PROBLEMS ON THE HORIZON ?
HOSPICE NOW A $4.5 BILLION
PER YEAR INDUSTRY
40% OF HOSPICES ARE NOW
“FOR PROFIT”
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AND COSTS ? 29% HIGHER/PT
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AND NOW ? FRAUD ? LAWSUITS ?
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IS THERE ANY CHANCE
THAT WE CAN
COME
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TOGETHER AND ALL
BE
OF ONE “MIND” - BE
IT
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CAN IT BE DONE ?
YES, IF WE RECOGNIZE THAT….
“EVERY GREAT ACHIEVEMENT IS A
BIRD ON THE WING.”
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JOHANN WOLFGANG von GOETHE
“AS LONG AS YOU
ARE NOT AWARE OF
THE CONTINUAL LAW
OF DIE AND BE
AGAIN,
YOU ARE MERELY A
VAGUE GUEST ON A
DARK EARTH.”
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HEMINGWAY - 1960
“THE WORST DEATH
FOR ANYONE IS TO LOSE
THE CENTER OF HIS BEING,
THE THING HE REALLY IS”
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IS THERE A TIME AND A PLACE HERE
TO SAY…………………
2011 - 22% OF DEATHS OCCURRED
IN AN ICU
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THE GRATEFUL DEAD
STANDING IN A SHAFT
OF LIGHT
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RISING UP TO
PARADISE,
I KNOW I’M GONNA
SHINE
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ACCEPTANCE OF DEATH WHEN
IT ARRIVES IS ONE THING, BUT
TO ALLOW IT TO UPSTAGE THE
JOYS OF LIVING IS INGRATITUDE
LIFE – A CIRCLE OR A LINE ?
“ I LIVE MY LIFE IN
WIDENING CIRCLES
THAT
REACH OUT ACROSS
THE
WORLD. I WILL NOT
COMPLETE THIS LAST ONE,
BUT I GIVE MYSELF TO
IT”
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MORTALITY AND MORALITY
HONOR CHOICE AT THE END OF LIFE
SO THE QUESTION IS NOT
“WILL I DIE?”
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BUT
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“WHEN AND HOW?”
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NO, LIFE & DEATH ARE NOT “THE FLAT
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THERE ARE TWO KINDS OF LIGHT
THOSE THAT GLOW
AND ILLUMINATE
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AND
THOSE THAT GLARE
AND OBSCURE
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“NOT A SHRED OF EVIDENCE EXISTS IN FAVOR OF THE
ARGUMENT THAT LIFE IS SERIOUS, THOUGH IT IS OFTEN HARD
AND EVEN TERRIBLE. SINCE EVERYTHING ENDS UP BADLY FOR
US, IN THE INESCAPABLE CATASTROPHE OF DEATH, IT SEEMS
OBVIOUS THAT THE FIRST RULE OF LIFE IS TO HAVE A GOOD
TIME; AND THE SECOND RULE OF LIFE IS TO HURT AS FEW
PEOPLE AS POSSIBLE IN THE COURSE OF DOING SO. THERE IS
NO THIRD RULE.”