Hospice: Prescription for Terminal Care (review)

Hospice: Prescription for Terminal Care. By Kenneth P. Cohen. Germantown, Md.: Aspen Systems, 1979. $27.95. Mr. Kenneth Cohen, a health care administrator from Southern California, has written a naive and troublesome book about his prescription for terminal care in this country. From the very first chapter, we are confronted with an adversary position between people who wish dignified terminal care and the medical establishment. "Help me die, please give me something! I don't want to live like this, please!" is Cohen's opening line. He goes on to describe a hypothetical patient who suffers a protracted and painful death attended by uncaring physicians and staff. If most of medicine were really like this, there would be a wholesale revolution and Cohen knows it. Yet he goes on to tell us that terminal illness is painful, often because of a malignant process, and that the acute general care hospital and most physicians are unable to cope with this dilemma. His solution is to create a new cadre of health care professionals who would maintain and service the dying through hospice facilities. This would include physicians, clergy, nurses, occupational therapists, dieticians, physical therapists, and numerous but caring "volunteers" who would spend hours with the dying patients, making their final hours peaceful and the death process a contented one. Cohen's troubles start immediately when the definition of a "terminal illness" is not made available. We are all terminally ill. What he really means is that some patients, because of illness or trauma, have a shorter expectation of living than they would have otherwise. Assuming that this point can be defined, Cohen would then urge such individuals then be transferred to the care of a hospice team where "care," not cure, is the modus operandi. Unfortunately, Cohen is quite wrong when, time after time, he implies or declares outright that physicians only try to cure but do not care. It is suggested that patients avail themselves of hospice care so that they can escape the clutches of physicians who ignore their severe physical and spiritual pain. The fact that most patients choose not to go to a hospice but remain with their physician or cling to the hope that experimental therapy may be useful or helpful to others is ignored. Cohen urges that additional public moneys be made available to the hospice care community so that it may train this army of health care workers (the same kind of workers that are currently available in hospitals), and that legislation be enacted that recognizes and makes easier the economic and administrative management of hospice facilities. He urges additional legislation that would remove from that one individual who knows the most about medicine, the physician, decisions which might otherwise impact upon how patients sometimes die. For example, he urges that a review board for the terminally ill be available in hospitals which wouldjudge whether support facilities could be removed or not. Where Cohen ever gets the idea that other human beings will be any more adept or astute at dealing with sick people, I do not know. What is even less clear is how Cohen would set about training individuals in the care of the dying and death. It is one of our social maladies. Worse yet, Cohen offers no assurances that hospice facilities will not go the way of nursing homes. The nursing home industry is a national disgrace, yet the hospice movement is taking the same economic and Perspectives in Biology and Medicine, 25, 2 ¦ Winter 1982 333 political road that the nursing care institutions and movement began shortly after World War II. There are a number of issues which Cohen raises in which I am in total agreement. Many physicians do not use adequate doses of narcotic analgesics, spend enough time in explanation of options, or help patients and families deal with their separation anxieties, sadness, or grief. But rather than encourage or otherwise help promote the installation of such models in the medical community , Cohen would set about to establish an adversary establishment that sets itself up as uniquely suited to deal with dying patients. Unfortunately, his book mostly reads like a political pamphlet rather than a useful guide...