the big windows overlook the well shrubbed hospital terrace which will be furnished with tables, chairs, and gaily colored sun umbrellas during the summer season. In the center of this triangular patient bedroom section there is a completely open, attractive, light, friendly nursing station. At Calvary, the patient may choose for himself. With an open door, he has a view of the nursing station and the people whom he depends upon for assistance; with a closed door he has total privacy. There are new hospitals and hospice facilities under construction which do not provide private rooms for terminally ill patients. Ms. Tregde feels this is an error. "When you have a headache, where do you want to be?" she asks. Then she answers her own question with a single word "alone." Lorraine Tregde admits that she had to put up a vigorous fight to obtain 6x6 foot windows for her hospital rooms. "The pleasure of experiencing the light and the life of the world through a hospital room window is often the only pleasure these patients have left. We must make it available to them," she kept insisting, ultimately with success. The bedrooms are adequate in size, 9 x 12 feet, ample space for an electric hospital bed, a lounge-bed wheel chair, a desk built in under the large window. Opposite the bed, high on the wall, is a color TV set equipped with a remote control so that the patient can operate it himself. Two levels of indirect lighting are available. In the wall near the head of each patient's bed, built-in oxygen and suction systems are provided. On the exterior wall of the building, between each pair of private rooms is a bathroom accessible from both sides and shared by two patients. Each patient unit consists of a nursing station and 12 pairs of two private rooms, plus a single isolated room with its own bathroom facilities. The isolated room is required under hospital construction codes. In the broad base of the V-shaped building serving two patient units there is a spacious day room with large windows overlooking the hospital terrace. Behind it there is a fully equipped kitchen-pantry. In the mornings this kitchen is used for preparation of patient breakfasts, cooked to order and served to the patients either in their own rooms or in the day room. During the day it is used for support feedings. Microwave ovens are available so that food can be reheated quickly, for example, if family members bring favorite foods from home. Routinely lunch and dinner are prepared in the central kitchen in the basement. Tregde looks forward to organizing a schedule by which one day each week a main meal will be prepared so that the patients can enjoy the smells of food being prepared in their immediate neighborhood. No effort is spared to provide patients with foods they particularly like and request. Also, a patient refrigerator in each nursing station is well stocked with beer, wine, and soft drinks which are available to the patients at all times without extra charge. The basement of the hospital contains the employee entrance, security, maintenance and building services, the central sterile supply, central stores, pharmacy and laundry, and the kitchen and employee cafeteria. The first floor houses the lobby, the business office, admitting room, auditorium, public coffee shop, and access to the terrace. For Calvary, the ambulatory care section which is also located on the first floor is a brand new service. It is at once a pre-admission evaluation clinic and an outpatient clinic for post-discharge patients. (Although patients admitted to the hospital are all considered terminally ill, some recover sufficiently to return home for shorter or longer periods.) Until this writing Calvary had not been authorized to provide home care of any kind, or to send staff doctors to visit patients in their own homes. Creation of a hospital team to provide home care backup-doctor's visits at home, nurse practitioners, and assistance to families willing and able to look after terminal cancer patients at home for shorter or longer periodsare on the Calvary agenda for the not-too-distant future. The ambulatory care section with outpatient facilities should be an integral part of the new supplementary service beginning January 1, 1979. Immediately adjacent to the Ambulatory Care Department is a dental facility. Complete dental care is available for patients with all new equipment including a dental X-ray unit. The second floor of the new hospital is devoted to the administration, nursing administration, medical staff, radiology, clinical laboratory, and surgical suite facilities. Here too, Richard Kelly, director of social work, has his offices. The department of social work provides counseling and supportive services for patients and their families who are trying to cope with the day-today crises associated with living with cancer. Group meetings to help families understand all aspects of the care provided for the patients and to help with any long-range problems that may arise are scheduled, in addition to private discussions. Members of the social work department staff have offices on every patient unit floor (floors 3,4,5, and 6). The Department has plans to extend their hours to include weekends, evenings, and holidays. The Medical Philosophy Calvary is a hospital devoted to care of terminally ill cancer patients, not to their cure. Doctors here believe that medical heroics of the type which may prolong a patient's life clinically for a few weeks or months while contributing virtually nothing to the quality of the patient's existence are counterproductive. Such heroics are not considered desirable here and the operating room does not get extensive use. Cardiac resuscitation equipment is available, but almost never used. Of course a patient who suffers a fracture or other injury which requires attention, receives all necessary medical care which will contribute to his comfort and well being. The result of this philosophy is the absence of large amounts of expensive sophisticated equipment in the operating rooms. Thus expenses for medical care at Calvary are low in comparison with costs at intensive care units of other hospitals. Per diem rates, though astronomical compared with just a few years ago, are considered modest at $250 which covers the costs of doctors, all medication, room, board, and nursing care. Dr. James E. Cimino, Medical Director of Calvary, heads a staff of 10 full-time physicians, plus a large number of associate and consultant physicians. Best known to physicians for his pioneer work in the development of kidney dialysis techniques, Dr. Cimino joined the Calvary staff more than 10 years ago to help the nuns achieve hospital accreditation standing for Calvary. Writing in the 1976 annual report, Dr. Cimino said, "With the realization that the new hospital will become a reality in 1978, the medical staff is in the process of re-examining its priorities to insure that the major thrust of the program remains patient oriented, rather than disease oriented." Speaking more informally in his office at Calvary, Dr. Cimino put the same theme in another way. "Whatever we do well here at Calvary, and whatever hospice type care centers do well, good doctors have been trying to do well for centuries, trying to give aid and comfort to people who have gone beyond hope of a recovery. "I believe that sickness should be handled in a home environment if possible," Dr. Cimino continued. This modern doctor believes in old fashioned virtues-doctors who make house calls and doctors who find time to give support to the families of the terminally ill. Though Calvary is now located in a brand new facility, the oldfashioned values remain uppermost. Welfare of the patient comes first here. This is not a teaching hospital in the conventional sense. Medical students, for example, are permitted to observe what is happening in the hospital, but are not allowed to assist in the actual treatment of any patients. What distinguishes Calvary from all other hospitals in the States is the fact that everyone who arrives in this hospital is terminally ill. For these patients it is too late for cures. The operations, radiation, and chemotherapy treatments have been tried elsewhere. They may have gained a "stay of execution" but now the doctors are aware that the end of the road is in sight. The patients have been, in the words of the 1902 annual report, "declared incurable and inoperable." Calvary Hospital takes these patients, and makes a tremendous effort to see that they are able to end their lives in a dignified, humane fashion. The philosophy of the hospital is very simple, very basic. Most important of all, with very few exceptions, the patient is entirely aware of his situation. No staff person insults the intelligence of the patient with dishonest reassurances about his forthcoming recovery. Whatever we do well there at Calvary, and whatever hospice type care centers do well, good doctors have been trying to do for centuries, trying to give aid and comfort to people who have gone beyond hope of a recovery. There is a very high ratio of staff to patients. Whereas, two staff members for every patient is normal in a conventional hospital, at Calvary there are three staff members per patient. Not all of the staff is medical. There are social workers, chaplains, and other people with various religious backgrounds in the major religions: Catholic, Protestant, and Jewish. They visit regularly with all patients and help with unfinished family problems a patient may wish to put in order before he dies. His emotional, spiritual, and practical problems are dealt with in a sympathetic, realistic, and helpful manner. The physical comfort of the patient is also given major attention. Pedicures, manicures, and shampoos are part of the program. The patient is kept immaculately clean even if this involves changes of linen virtually hourly. There are no unpleasant smells, no rooms with drawn shades; instead there is a warm, friendly atmosphere, large windows, brightly colored walls, an open attitude, no secrets, and no hushed voices. Visiting hours are routinely from twelve noon to 8 p.m. and children are welcome. However, when a patient is placed on the critical list, visiting hours are expanded to around the clock. Spiritual Help Sister Agnes Connors, a serene nun on the Calvary staff, is happy to talk to visitors about the work of her department. "We have more intensive spiritual care here. Half of our patients have no regular visitors. They need someone to hold their hand, to care about them, to share their concerns. Being here, one sees values in a different way, learns what is really important in a person's life and in his death." Sister Agnes is responsible for a Pastoral Care Department which is nominally open from 8:30 a.m. to 8 p.m., but in point of fact, staff members from the department are available whenever and wherever the need arises. The department is staffed by a full time chaplain and three pastoral associates assisted by a part time rabbi, two part time ministers, and a Spanish speaking priest. "We have some ecumenical services here," Sister Agnes told me. "A person's relationship to God is personal. No one has a right to intrude on it. I have encountered very few patients here who are truly atheists. I try to help these people too if I can. 'Would you like me to pray with you, or for you?' I ask them. I try to help our patients make each day liveable and tolerable, help them to try never to give up hope. I try to leave no question they ask me unanswered. I have learned to be less judgmental at Calvary," Sister Agnes says thoughtfully. "I accept people's lives and their ways of meeting death less critically, more philosophically. All of us here try to stand with our patients, to listen to them, to be a helpful presence to them in their final days of life. That applies not only to doctors, nurses, and spiritual helpers, but also to our social workers and our housekeeping staff." Staff Recruitment Is it hard to get staff for a hospital where the average length of stay is 55 days and the normal reason for departure is death? Surprisingly enough to the outsider, there is no problem of this kind. Calvary has the lowest employee turnover of any hospital in the city, only 1 percent per month. People who leave do so mostly during the first three months of employment. Others, attracted by the warm human atmosphere, stay for many years, usually working up to positions of ever greater responsibility. And In Conclusion Lorraine Tregde, Executive Director of Calvary Hospital and President of the Hospital Corporations Board of Directors, has a brace on one leg and a crutch under one arm, permanent reminders of her own bout with a near fatal case of polio at age 16. Despite these handicaps, she is a physically vigorous woman who put in seven Patient care begins with a strong feeling that patients should be as comfortable as possible during the latter days of their illness. day work weeks regularly while the new Calvary was under construction." "I don't know how to handle the dying patient"", Tregde told me bluntly. "All I know how to do is to handle each person in this hospital individually, to do the best I can to see that his or her needs are met adequately." In an age where everything about life, including death, has acquired labels and pigeon holes for behavior and treatment, it is refreshing to encounter people who have returned to care of the individual patient. It is inaccurate to use the phrase "returned to the care of the individual patient." Indeed, the Ladies of Calvary launched that approach in New York's Greenwich Village in a modest house on Perry Street in 1899. And Calvary has never deviated from it. If the widows who worked in The House of Calvary so long ago were to return to visit Calvary Hospital, their brand new namesake in the Bronx, they would find that though the building is unlike anything they might have imagined at the turn of the century, their same spirit of caring for the physical and spiritual needs of the terminally ill on a completely individual basis is still alive and well at Calvary. Hospice John W. Abbott* M any Americans, when confronted with a diagnosis of a terminal illness, have been told that there is nothing more that professional health personnel can do. The result of this has been that many patients are forced to live out their remaining days experiencing pain and other symptoms without adequate medication to relieve their discomfort and suffering. Their psychological, social, and spiritual needs have also been ignored, and their families have had to cope alone during the traumatic period of the illness as well as in the bereavement period following. The result has been that many have died without anything resembling a sense of fulfillment. When Hospice, Inc. of New Haven, Connecticut began to care for terminally ill patients in their own homes, and to work with their families as well, an important new approach to health care was inaugurated. The date was 1974. Though St. Christopher's Hospice had opened its inpatient doors in London in 1967, the New Haven program was the first in this country. With the help of a three-year contract with the National Cancer Institute, Hospice, Inc. was able to run a national demonstration center for home care of the terminally ill and their families. Since that 1974 beginning, Hospice, Inc. *Mr. Abbott is Director of Public Information for Hospice, Inc. of New Haven, Connecti cut. has cared for nearly 600 patients and their families. The movement has spread rapidly throughout the country since then. About 200 hospice programs are in various stages of planning and development in 39 states plus the District of Columbia, and the number is growing. The National Hospice Organization, which brought nearly 1,000 people to the Fifth National Hospice Symposium in Washington, D.C. in October, 1978, is providing signal leadership to the movement with special attention to the implementation of standards for local hospice programs of care. NHO accreditation will be necessary for use of the "Hospice" name. Many important questions are being raised about Hospice, and this article will answer some of them. The Goals of Hospice The Goals of the Hospice program are succinct and compelling: • To enable the patient to live as fully as possible. • To support the entire family as the unit of care. To make it possible for the patient to remain at home as long as home care is appropriate. • To supplement rather than to duplicate existing services. To keep costs down. Hospice Aids the Patient and His Family. Patient care begins with a strong feeling that patients should be as comfortable as possible during the latter days of their illness. Such comfort comes about through regular control of pain and management of the numerous symtoms (such as nausea, shortness of breath, etc.) associated with terminal illness. If the patient's condition warrants, medication is administered on a regular basis before the patient actually feels the need. The source of what the patient interprets as pain must often be tracked down and help provided to meet each symptom. The aim is to find the point at which discomfort stops but before sedation is effected. Hospice recognizes that a terminal illness affects every member of the family. Sometimes what is needed is a sense of assurance that help will be available in the event of an emergency in the middle of the night or on a holiday weekend. Hospice staff make regularly scheduled visits but are available 24 hours a day, 7 days a week to make house calls when their help is especially needed. Another concern expressed by family members is whether they will have sufficient information and knowledge with which to provide the care which they desire to give. When people ask, "Can we care for our loved one?" Hospice answers "Yes, you can, and we will help you." Thus Hospice teaches family members how to care for patients, how to give medications, how to prepare tasty but nutritious foods and other practical things. Hospice also educates the family regarding the progression of the illness so that no one will be surprised by new developments. A major characteristic of Beyond these matters, often what is needed is simply a feeling-demonstrated by positive action-that someone really cares about the family enough to take time to listen to family problems, needs, fears, and anguish. Hospice staff and volunteers must be good listeners. A visit from the Hospice home care team is not a brief in-out encounter but an experience which lasts as long as necessary to meet needs as they arise at any given moment. Many family members have said, following the death of the patient, "You helped us to do what we wanted to do." Family care continues throughout the bereavement period. Every family, following the death of the patient, receives a visit from the nurse who carried the primary responsibility, as well as periodic telephone calls. If the family needs additional help in coping during that difficult period a volunteer bereavement team assumes a continuing role for as long as its help is needed. Providing Care Care is provided by an inter-disciplinary team which is medically directed and nurse coordinated. Individual team members include physicians, nurses, a social worker, and chaplain; oncall consultants including a psychologist, dermatologist, and physical therapist; and trained home care volunteers. An individual plan of care is worked out for each patient and family, and the entire resources of the team are available to meet individual needs as they develop. Eligibility criteria for patient care include: A diagnosis of cancer. (Hospice hopes to care for persons suffering from other conditions after its inpatient facility is opened.) • A limited prognosis (six months or less). • We prefer that there be a primary care person in the home. Usually this would be a relative, occasionally a friend, who is able to take continuing responsibility for patient care. • Consent and cooperation of the patient's physician who usually remains the primary physician on the case. • Residence in one of 12 cities and towns in the area of New Haven, Connecticut. Ultimately the home care program will be expanded to a 20 town area which comprises an HSA (Health System Agency) region, one of five in Connecticut. Hospice Volunteers Hospice has several physicians and nurses who provide volunteer service in addition to paid staff members of those disciplines. Other volunteers read to patients, provide automobile transportation, stay with the patients while family members go out of the house, assist family members with chores, and do whatever most needs to be done. One volunteer took a patient, a life-long fisherman, fishing, because |