Death, Society, and
Human Experience
9th Edition
Robert Kastenbaum
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Chapter Five:
The Hospice Approach to
Terminal Care
This multimedia product and its contents are protected under copyright law. The following are prohibited by law:
•Any public performance or display, including transmission of any image over a network;
•Preparation of any derivative work, including the extraction, in whole or in part, or any images;
•Any rental, lease, or lending of the program.
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Copyright © Allyn & Bacon 2007
Hospice: A New Flowering
from Ancient Roots
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Earliest hospice care was likely undocumented
4th century – found in infirmaries in early Christian
Greek-speaking areas, then spread to Europe
Well established by the 5th century, continued to
flourish until the movement faded during the
Protestant Reformation
19th century – reappeared in small, isolated areas
Major development in 1967 – Dr. Cicely Saunders
starts St. Christopher’s Hospice in London
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Spirit of the Modern Hospice
Movement
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Dr. Cicely Saunders gained insight from a
background in philosophy, nursing, social work,
and medicine
• Kastenbaum’s observations
• Promoters of hospice have been mostly women
• Unique personal interactions and relationships have
been emphasized
• Attitude that the patients know better than physicians
what they need when dying
• Attitude that all are free to make their own meaning
regarding death (hospice does not promote religion)
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Proposed Standards: International
Work Group on Death and Dying
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Patients, family and staff all have legitimate needs
and interests.
• The terminally ill person’s own preferences and
lifestyle must be taken into account in all decision
making.
• Standard were separated into:
• Patient-Oriented Standards
• Family-Oriented Standards
• Staff-Oriented Standards
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Patient-Oriented Standards
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Remission of symptoms is a treatment goal
• Pain control is a treatment goal
• The patient’s intentions will be respected as one of the
main determinants of the total pattern of care
• The patient should have a sense of basic security and
protection in his or her environment
• Opportunities should be provided for leave-takings with the
people most important to the patient
• Opportunities should be provided for experiencing the final
moments in a way that is meaningful to the patient
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Standards for Family and Staff
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Family-Oriented Standards
• Families should have the opportunity to discuss dying,
death, and related emotional needs with the staff.
• Families should have the opportunity for privacy with the
dying person both while living and immediately after
death.
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Staff-Oriented Standards
• Caregivers should have adequate time to form and
maintain personal relationships with patients.
• A mutual support network should exist among the staff.
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National Hospice
Reimbursement Act of 1983
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Established a Medicare Hospice Benefit
Three conditions must be met:
• Patient’s physician and the hospice medical
director certify that a patient has a life
expectancy of 6 months or less
• Patient choose to receive care from a hospice
as an alternative to basic Medicare coverage
• Care is provided by a hospice program certified
by Medicare
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Hospice-Inspired Care for a
Variety of People
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Family members at home, in respite
facilities, and in medical care facilities
Those with less traditional religious beliefs
Children
People with AIDS
Those outside the mainstream, such as the
homeless and prison inmates
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Hospice Care on the
International Scene
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Hospice care growing rapidly throughout much of the world
Great variation in size and characteristics
Most medical systems show resistance to hospice at first
Pain control remains the central objective
Education for patients, medical care providers, government
officials, and societies has been a priority
Most clients
• Between 60 and 79 years old
• Equal use by women and men
• Choose home care
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Why Pain Must Be Controlled
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Pain is, by definition, a stressful experience
Pain reduces the ability to give attention to other
matters, thereby isolating the sufferer and
reducing opportunities to reflect or interact
Pain can intensify other symptoms, such as weight
loss, insomnia, pressure sores, and nausea
Fear and anticipation of pain can be demoralizing
Pain contributes much to anxiety about the dying
process
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Pain Relief without
Surgery or Drugs
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Reduced Mental Distress
Supportive Social and Familial Relationships
Company of Companion Animals
Massage
Application of Heat, Cold, Menthols or Electrical
Nerve Stimulation to the Skin
Careful Positioning and Exercising
Hypnosis
Guided Imagery
Aroma Therapy
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Other Common
Symptoms and Problems
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Nausea
Vomiting
Dypsnea
(respiratory
difficulties)
Pressure sores
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Insomnia
Incontinence
Weakness
Fatigue
Confusion
Depression
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Your Last Three Days
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Patients in a national hospice study were asked
how they would like their last three days of life to
be. They responded (in order of importance):
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I want certain people to be here with me
I want to be physically able to do things
I want to feel at peace
I want to be free from pain
I want the last three days of my life to be like any other
days
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Sources of Strength
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Hospice patients were asked about their
primary sources of strength. They
responded (in order of frequency):
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Supportive Family or Friends
Religion
Being Needed
Confidence in Self
Satisfied with the Help Received
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Common Barriers to
Hospice Service
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Physicians’ difficulty with hospice admission
criteria, reluctance to lose control of their patients,
and restrictions on the number of pain control
prescriptions they are allowed to write
Insufficient family cooperation with hospice
Inadequate communication between managed
care health staff and patients or families
Late referral of patients to hospice care
Availability of family support
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A Hospice Volunteer
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Be a companion for a patient
Drive a patient to the doctor or on outings
Help the patient write letters
Help prepare meals
Work with the organization itself by doing
paperwork, fund-raising, or other office-type
jobs
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Glossary: New Terms
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Amyotropic Lateral
Sclerosis (ALS)
Catchment Area
Hospice
Medical Hospice
Benefit
National Hospice
Study
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Palliative Care
Remission
Symptom
Terminal Illness
Vital Signs
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