Donna White once wished for pills, poison, starvation, anything that would end her torment. She bought the Hemlock Society's best-selling suicide guide Final Exit, looked for a doctor who would provide the lethal drugs, and prepared to end her life. Like most people who face death, White had three fears: she didn't want to die in pain, she didn't want to die alone, and she didn't want to bring great financial or emotional cost to her family. The only solution to these fears that she knew of was suicide. While searching for a doctor to provide her with the deadly dose, White found a better solution: hospice.

Like 250,000 other terminally ill Americans each year, Donna White found in hospice care the solution to her three driving fears. She would not have to die in pain, because a hospice nurse who specializes in pain relief joined with her doctor to find a more effective combination of drugs to minimize the pain and taught White how to control the amount of drugs she needed. "Once they got my pain under control, I started thinking with my heart," White says. She wouldn't have to die alone, because the hospice concept is built around an integrated support network involving family, friends, medical and spiritual assistance. Finally, she wouldn't bring great financial or emotional loss to her family, because hospice care is considerably less expensive than hospital care, with whatever costs that are not paid by Medicaid underwritten by outside sources. The integrated support of family and friends to the dying process, plus subsequent bereavement counseling, gave White assurance that the emotional cost would also be lessened by the hospice approach. [1]

There are now almost 2000 hospices throughout the United States. As the nation debates issues surrounding health care and costs, euthanasia and assisted suicide, and the patient's right to autonomy in determining the extent to which aggressive curative therapy should be administered, only one approach adequately resolves the issues involved: hospice. As ABC's medical editor Dr. Timothy Johnson, also an ordained clergyman, says, "We should be doing far more in our health-care system to develop and support local hospices. If hospices were geographically and financially available, I believe that the person considering suicide would prefer the hospice. In fact, if we did an adequate job of providing such care, the issue of physician-assisted suicide would largely disappear." [2] If it is going to faithfully care for the dying, the church must actively promote and support hospice.

The Present Debate

Modern medical technology offers many ways of aggressively combating cancer and other terminal illnesses, yet it often fails to consider the physical, emotional, spiritual, and financial effects of such treatment on the patient. Increasingly, patients are seeking to take control back from the medical technologists, to say when aggressive therapy aimed at a cure should be suspended. This has resulted in the present surge of interest in living wills and the durable power of attorney. Through these means, patients may now declare the extent to which treatment should be pursued in the attempt to restore them to health or keep them alive. Patients may now declare when treatment should be halted so that they may die with dignity and not be kept alive artificially by a connection to a machine. Based on the patient's advanced directive, life-sustaining technology may be withheld or withdrawn so that the disease may take its course and death result.

The desire to reclaim control over how one dies has led many to the advocacy of active euthanasia and assisted suicide, in which active measures are taken to effect death. In active euthanasia, the doctor acts deliberately to cause death, usually by giving the patient a drug overdose. This practice was brought to the fore in an anonymous account of a gynecology resident's decision to inject a young cancer patient with whom he had no prior acquaintance with a lethal dose of morphine. Entitled "It's Over, Debbie," this article elicited a storm of physician outrage for its attack on medical protocol and its violation of the hallowed canon of medical ethics expressed in the Hippocratic oath: doctors must not kill. [3] In physician-assisted suicide, the doctor gives the patient the drugs and counsel necessary to administer the lethal dose himself. In 1989, physician-assisted suicide was granted a veneer of medical acceptability when the prestigious New England Journal of Medicine ran an article in which ten out of twelve physicians endorsed physician-assisted suicide. [4] That some doctors see little wrong with killing is becoming more evident. When Dr. Timothy Quill, a Rochester, New York physician, reported in the New England Journal of Medicine in 1991 that he had given instructions and adequate supplies of barbiturates so that Diane, a cancer patient he had known and treated for years, could and did kill herself, no outcry occurred such as had followed the publication of "It's Over, Debbie." In fact, what followed was mostly approval. The fact that Quill had a prior relationship with his patient in which he offered medical care with deep concern for the patient's well being seemed to justify his act to many physicians. [5]

There is increasing support for euthanasia and assisted suicide in the United States. In November, 1994, Oregon voters passed the so-called Death With Dignity Act, also known as Measure 16, which permits physicians to prescribe lethal drugs for terminally ill patients. As is the case with the active euthanasia permitted in the Netherlands, the Oregon measure contains certain stipulations which are intended to arrest the possibility of abuse. This is purportedly ensured by a terminal diagnosis of the patient, concurrence by a second physician, testing for depression, repeated requests at specified intervals, self-administration of the dosage, and family notification. As is the case with the Dutch experience, however, once on the slippery slope, the safeguards against abuse are regularly overlooked and even legally permitted so that euthanasia may be foisted on a patient who is not terminally ill and who has made no such request. [6]

According to Sherwin Nuland, M.D., author of the 1994 National Book Award winning How We Die, 57% of Americans now approve of some form of physician-assisted suicide. Although he is committed to the concept of euthanasia, Nuland acknowledges that "euthanasia is killing." His concern about the "slippery slope" moves him to suggest a series of steps to safeguard abuse: (1) A request by a patient or family member to end life must be defensible; they must have examined all the alternatives and not be in a state of depression treatable by therapy or drugs, (2) If after a reasonable challenge the doctor is convinced that a request for death is appropriate, another specialist should be consulted, as well as experts in the field of palliative care (symptom control and comfort care), (3) the request for euthanasia be made to a "council of sages" made up of educators, civic leaders, philosophers, clergy, lawyers, or other laypeople with "collective wisdom." Nuland concludes, however, that such requests for death will be minimal when proper care is given to those who suffer. "In my experience, most people who ask for death do so because of symptoms or a state of mind that can be relieved by proper attention and consultation. When the symptoms lessen, these people no longer want to die." [7]

The Hospice Alternative

Advocates of assisted suicide and euthanasia seek to help people die in comfort and with dignity. How dignified is it, however, when a doctor, charged with care and cure, actively kills his patient or provides the means for the patient to do it himself? Such an approach must be resisted by those committed to Holy Scripture, particularly on the basis of the sixth commandment not to kill. The Westminster Shorter Catechism says, "The Sixth Commandment requireth all lawful endeavors to preserve our own life, and the life of others" (Q. 67). The Heidelberg Catechism states that the sixth commandment requires "that I do not harm myself or willfully expose myself to danger" and that the Christian "prevent injury" to his neighbor "as much as we can" (Qs. 105, 107). Scripture's affirmation of the sanctity of all life and its prohibition against doing injury or harm to ourselves or to others compels a different approach to helping people die in comfort and with control and dignity than the misguided proposals of euthanasia or assisted suicide. The Christian approach must be that of hospice. The Anglican Bishop Maurice A. P. Wood has remarked, "A strong supporter of euthanasia once told me that only the hospice movement, undergirded by the religious stress on the sanctity of life, could withstand the demands of euthanasia." [8]

Hospice is an approach to care that is designed to support the physical, psychosocial, and spiritual needs of people who are terminally ill. It is a physician-directed, nurse-coordinated, interdisciplinary approach to patient care available twenty-four hours a day, seven days a week. Its goal is to allow the dying process to unfold with a minimum of discomfort and to maintain patient dignity and quality of life to the end. Care is provided by family and friends at home or in a home-like setting within a hospital or special facility. The hospice team, which in addition to the patient's physician and the hospice nurse also includes social workers, chaplains, and volunteers, addresses the needs of the patient as well as those of the family members during the process of death and following its occurrence.

"Hospice" and "hospital" both come from the Latin word hospes, which meant both host and guest. This idea of reciprocity of care in community is central to the hospice idea and markedly distinguishes it from the modern hospital. "From hospes to hospital, the psychology has changed from one of love to one of war, and in the psychology of war, force is imperative. Therefore we arrive at the strange, new embrace that pins the inert body of a man or woman, terminally ill, to a machine that forces that person's body to breathe without even knowing its name." [9] The aggressive approach of the hospital construes the disease as an enemy to be defeated, while the physical, emotional, and financial pain that results from this aggressive treatment on the patient is often regarded, in military euphemism, as "collateral damage." With treatment options for cancer and other terminally ill patients greater than ever, the scope of the modern hospital is almost exclusively curative and all the weapons at its technological disposal are launched in the effort to destroy the enemy of health, disease. While the treatment of those who can be cured has vastly improved in the twentieth century, the way the terminally ill are cared for has grown steadily worse.

Doctors are simply not adequately prepared for treating the terminally ill. "It is regrettably true that the majority of physicians in the United States have never been taught the techniques of treating the physical, psychological or emotional symptoms of terminal disease." [10] Medical students often have but one course in pharmacology and drug therapy. They fail to appreciate the pain of their patients and do not treat that pain effectively. This is only now being rectified. In December, 1993 the American Medical Association, as part of its new resolution against euthanasia and assisted suicide, resolved to promote better pain control for dying patients. Early in 1994 the U.S. Agency for Health Care Policy and Research issued new guidelines on "Management of Cancer Pain," admitting that while cancer pain can be managed effectively through relatively simple means in up to 90% of the eight million Americans who have cancer, pain associated with cancer is frequently undertreated. Asserting that drug therapy is the cornerstone of cancer pain management, the guidelines say "an essential principle in using medications to manage cancer pain is to individualize the regimen to the patient." [11] These and similar recommendations which are now being urged upon oncologists and others treating the terminally ill have been known to hospice physicians and nurses for decades.

Chronic pain can render life meaningless and enhance the desire for the end. Some Christians think the inability to find meaning in pain is a major reason for the promotion of assisted suicide in contemporary society. "The most compelling reason why physician-assisted suicide is becoming a reality is that our postmodern, technological culture cannot find meaning in suffering. The patient has no framework for dealing with pain and hopelessness and therefore struggles for answers" [12] These Christians are right to emphasize the need for faith in responding to pain, but their well-intended remarks can often sound callous to those who suffer unbearably. "Anyone who has worked with cancer or AIDS patients in pain realizes what nonsense it is to say that excruciating pain from a terminal illness has any redeeming value. This kind of argument from the opponents of euthanasia only strengthens the convictions of Hemlock Society supporters." [13]

The pain of cancer is particularly meaningless, serving no useful purpose, such as warning the sufferer of imminent harm. Unless appropriately treated, cancer pain usually grows more rather than less severe. Without adequate treatment, it frequently expands to occupy a patient's whole attention and isolates him or her from the world around. When this occurs, the patient may believe that life is no longer worth living. One survey reported that 69% of cancer patients would consider committing suicide if their pain was not adequately treated. [14]

The church's responsibility is to care for the dying, not simply to preach the redemptive value of suffering. It can do this through hospice.

The hospice approach is not concerned with aggressive cure of the disease, but with palliative care of the patient. Those who want aggressive efforts undertaken to cure their disease are not candidates for hospice care. Many people who are seriously ill and their doctors continue to search for new treatments even when it is apparent that nothing will arrest the spread of the disease. Hospice is for those who recognize that they are terminally ill and who desire no further debilitation from radical attempts at a cure. Medication is kept to a minimum and procedures such as IVs, transfusions, surgery, chemotherapy or radiation therapy are not used except for possible short-term palliative therapy for pain relief. Hospice is for those who, by their doctor's best evaluation, have a limited time left to live, usually six months or less. A patient can be considered to be irretrievably in the dying process if: (1) there is no treatment that will significantly alter the patient's disease, (2) the disease is progressive, (3) the goals are short, (4) the intent is not to prolong life, and even more to the point, the intent is not to prolong dying. [15] Hospice is for those who desire that their remaining days be spent in the company of family and friends, alert and with a minimum of pain and medical intervention.

Hospice is not a place, but an integrated program of caring. Hospice care can occur in resident facilities such as specialized sections of hospitals and separate buildings or it can occur at home. From its beginning in New Haven, Connecticut in 1974, hospice in the United States has emphasized in-home care. [16] Regardless of whether the hospice program is done at home or in a resident facility, it is completely unlike the sterility of the hospital setting. Hospice endeavors to approximate the normalcy of life as much as possible, since it views death as a normal part of life, not something to be hidden. As such, the normal life setting of the patient is encouraged, with unrestricted access to family, friends, and pets, all of which contribute to making life at the end as meaningful and enjoyable as possible. If depression or other circumstances have caused the patient to let his surroundings deteriorate, a family member or volunteer will clean up and help to reestablish a dignified environment.

Approximately 70% of the people in this country will die in an institution, removed from family, friends, intimate surroundings, and everything that has made their lives valuable. It was not, of course, always that way. Before modern medical advances, the family doctor used to come to the home of the dying patient and, with clergy and loved ones close at hand, provide care in the last days of life. Healing does not always mean curing. Sometimes it means helping the patient to prepare for death and to enjoy the last days of his life. Dame Cicely Saunders describes the archetypal hospice philosophy of St. Christopher's in England:

Healing a person does not always mean curing a disease. Sometimes healing means learning to care for others, finding a new wholeness as a family--being reconciled. Or it can mean easing the pain of dying or allowing someone to die when the time comes. There is a difference between prolonging life and prolonging the act of dying until the patient lives a travesty of life. At St. Christopher's, we try to offer people space in which to be themselves. We hold fast, but with open hands; because sometimes the most import part of loving can be knowing how and when to let go. [17]

While utilizing the latest advances in medical understanding to control pain and provide comfort in its palliative care, hospice returns to the holistic and integrated approach to death and dying of days gone by. Surveys report that 90% of Americans would prefer to die at home, in familiar surroundings, with family and friends nearby. [18] Hospice ensures that they can spend their final days meaningfully, virtually free from pain and in an environment and amongst people they know and love.

Hospice medicine successfully controls the symptoms of the disease so the patient feels little or no pain right up to the end. It provides regular nurse's visits to check on how the drug therapy is working and provides instruction to the patient and family on self-administration of dosages to manage pain and control nausea and vomiting. It provides nutritional counseling and evaluation of eating habits to enhance the patient's sense of well-being. Occupational therapy, physical therapy, and speech therapy are available, as is emotional and psychological counseling and support. Spiritual support and guidance is available, as virtually all hospices have chaplains who regularly visit the patient and assess needs. Home support services by hospice volunteers are also available, such as doing shopping for the family, providing transportation for the patient, and, perhaps most importantly, companionship, just being there to share with the patient for a hour or two a week. Volunteers also provide respite care for periodic relief of family members from the stresses of caring for the patient at home. Legal and financial advice are also available in preparation for the death of the loved one. Finally, hospice workers become so integrated into the family of the patient that they remain with them in and through the death of the loved one, providing bereavement care for the survivors following the time of death. Hospice thus provides holistic care for the terminally ill patient and his family so that the process of death may be one of dignity, love, and meaning for all involved.

The Church and Hospice

Hospice is a concept whose time has come, though it is hardly new. The roots of hospice go back to the first century church, when the hospitium served as a resting place for the hospes, the guest on his way to and from a pilgrimage. Fabiola, a disciple of St. Jerome, founded a hospitium in Rome nearly two thousand years ago to care for pilgrims returning from Africa. Other such way stations for the care of the needy traveler are known, such as the hospice of Turmanin in Syria in 475, but perhaps the most noteworthy is the care for the sick provided by the Knights Hospitallers of the Order of St. John in the twelfth century. Their statutes for the care of the sick call attention to the hospitality that was due to the guest (hospes). Hospitality and care for the sick pilgrim and weary traveler, whatever his worldly status, were central to these precursors to the modern hospice. Founded in the Christian conviction that all life has sanctity and dignity, these servants of God ministered faithfully to all in need as unto the Lord Jesus himself.

The first "hospice" so-called was founded in the nineteenth century by Mary Aikenhead and the Irish Sisters of Charity in Dublin. [19] Since then, particularly through the impetus provided by Dame Cicely Saunders, a devout Christian and founder of St. Christopher's hospice in England in 1967, hospices have arisen in all fifty states of the United States and in many foreign countries. Some remain church-based, such as Malachi House in Cleveland, [20] while many others are community-based care facilities founded out of a broader constituency but retaining the religious and spiritual aspect foundational to the holistic hospice concept. Often it has been clergy and concerned Christian laypeople who have been instrumental in forming hospice care in their area. This was the case with the formation of the first American hospice in New Haven, Connecticut in 1974 and has also been true as the hospice concept has taken hold in foreign countries, such as Japan, Taiwan, India, Korea, Singapore, and Hong Kong. [21] This is not always easy to accomplish, particularly since some cultures, such as the Japanese, have traditionally avoided discussion of the issue of death and have had nothing to do with the dying. [22] The holistic, integrated approach to death and dying that is foundational to hospice should, however, actually have greater appeal to non-Western cultures where community is emphasized over individualism and integration is accented over specialization and compartmentalization in thinking.

Hospice does provide a new opportunity for ministry by clergy and laity. [23] Clergy, of course, can play a vital role in ministering the love and grace of Christ to those who are terminally ill and in need of the hope and assurance that only the gospel can bring. They can do this not only among their own parishioners who are terminally ill, but among those in the broader community who are in a hospice program through service as a hospice chaplain. [24] Clergy can also be valuable in ministering to hospice workers themselves, providing them with counsel to relieve stress. [25] George Gates warns that pastoral counselors must assert their rightful role in the hospice program or it may well be relegated to another. "A risk exists that if pastoral counselors do not begin to assume their team role, they may relinquish this opportunity to other disciplines." [26] Even if they do not initially intend to become active in hospice, clergy can improve their ability to minister to the dying by taking the fifteen to twenty hours of volunteer hospice training that local hospices regularly provide. Certainly, clergy cannot afford to be unaware of what hospice is and how it can benefit the dying. It is, therefore, incumbent upon seminaries to include hospice in preparing students for ministry in church and society. [27] Continuing education of ministers must also include addressing the significance of hospice. Lay people also have a key role to play in hospice home support. They are needed to be a friend to the terminally ill patient and his family, to spend an hour or two a week just being a companion, and also to do helpful errands such as providing transportation, doing shopping, and perhaps occasional respite care. The layperson may feel initial reluctance to embrace this ministry based on a sense of inadequacy in working with the dying. Many of these feelings of reluctance are assuaged by the volunteer training that hospices require for all who work in the program. Lay people should also be aware that clergy also sometimes feel a sense of inadequacy in dealing with the dying. All who do work with the dying come to realize, however, that it is far less a matter of what one says as it is of what one is, a person who cares and makes that care evident in being there to help however he or she can. Those who do hospice work are those with some personal commitment to spiritual values and who enjoy helping and caring for others. While it is probably not for everyone, those who feel called to such work will find that they receive greater blessings from their work and their patients than they themselves give.

The Future of Hospice

Hospice is very likely the wave of the future in health care. "Hospice should be at the top of the agenda for health care reform in this country." [28] Health care providers are increasingly recognizing the benefits of hospice care.

Hospice care is generally recognized to be less expensive than hospital care. While the estimates of 30-60% savings compared to hospitalization have been questioned by some, [29] there appears to be no doubt that hospice does offer a cheaper alternative to radical and aggressive in-patient therapy. [30] Patient stays in the hospice program average 59 days with no expensive invasive procedures utilized except as needed for short-term palliative care. Not only does such an approach entail far less cost, but it also reduces the difficult decisions that sometimes have to be made regarding the utilization of invasive procedures of questionable worth. Cundiff says most people do not want artificial hydration and nutrition if they are terminally ill, since it induces significant pain. [31]

The public dialogue about whether nutrition and hydration must be provided at the end of life has enhanced the ability of hospice care providers to ensure patient comfort. Such measures now are generally assessed just as are any other medical treatment measures, with the benefits and burdens weighed relative to the patient's goals and values. Conventional replacement hydration commonly leads to oral and pulmonary secretions in excess of the dying patient's ability to handle them. Thus, forgoing the provision of nutrition or hydration by other than the oral route ordinarily enhances the patient's comfort during the last few days of life. [32]

By forgoing invasive means, hospice thus enhances the quality of the dying patient's last days and obviates troublesome ethical questions surrounding the use or withholding of artificial hydration and nutrition.

With the growing number of patients with end-stage chronic illness, including AIDS, seeking hospice services, average hospice costs will escalate. This is because AIDS patients may still benefit from costly medications and require higher maintenance care for longer and more unpredictable periods. Symptom control is a common and severe problem that remains difficult to improve in HIV/AIDS patients. [33] Thus, although 84% of hospice patients have been diagnosed with cancer, AIDS will continue to require greater attention among hospice care givers. It is generally agreed that AIDS does not fit the cancer model of hospice care and requires a different setup which is more costly and less definite in terms of beginning and procedure. [34] Psychosocial support is notably less among neighbors of AIDS patients and work among AIDS patients is more time consuming and stressful for hospice staff. [35] Notwithstanding, AIDS patients are more satisfied with hospice care than non-hospice care. [36]

Thus, although there are problems that remain to be worked out with hospice care as it ministers to those with AIDS, endeavors to be more responsive to those with other terminal illnesses, and seeks fiscal integrity and aims at the greatest accessibility, it seems clear that hospice is vital to future health care. The church must promote the hospice approach by reclaiming its historic role in caring for the dying and their families. It can do this by providing information on hospice and actively engaging in hospice support, both financially and through volunteerism. As the church engages in hospice work by ministering to those who are dying and their families, it will help to render moot the case that is made for euthanasia and assisted suicide. In so doing, it will demonstrate that the sanctity of life and the dignity of each human being are rooted in faithful commitment to God, who cares for the dying through his church and calls them into the true community that is consummately to be found in Jesus Christ.

Endnotes

[1] J. Shapiro, "Death on Trial: The Case of Dr. Kevorkian Obscures Critical Issues--and Dangers," U.S. News & World Report, April 25, 1994, pp. 31, 34.

[2] T. Johnson and C. E. Koop, Let's Talk: An Honest Conversation on Critical Issues: Abortion, Euthanasia, AIDS, Health Care (Grand Rapids: Zondervan, 1992), pp. 51-52.

[3] Anonymous, "It's Over, Debbie," Journal of the American Medical Association 259 (1988), p. 272; W. Gayland, et al., "Doctors Must Not Kill," Journal of the American Medical Association 259 (1988), pp. 2139-40.

[4] S. H. Wanger, D. D. Federmann, et al., "The Physician's Responsibility toward Hopelessly Ill Patients: A Second Look," New England Journal of Medicine 320 (1989), pp. 844-49.

[5] T. Quill, "Death and Dignity: A Case of Individualized Decision Making," New England Journal of Medicine 324 (1991), pp. 691-94; Correspondence: "Death and Dignity: The Case of Diane," New England Journal of Medicine 325 (1991), pp. 658-60.

[6] Cf. R. E. Otto, "Bottom of the Slope: The Dutch Slide Further Still," Commonweal 122, May 19, 1995, pp. 5-6.

[7] Nuland, "The Debate Over Dying," USA Weekend, February 3-5, 1995, pp. 3-5.

[8] Wood, Foreword, Death Without Dignity (ed. N. M. de S. Cameron; Edinburgh: Rutherford House, 1990).

[9] S. Stoddard, The Hospice Movement: A Better Way of Caring for the Dying, rev. ed. (New York: Vintage, 1992), p. 6.

[10] D. Cundiff, M.D., Euthanasia Is Not The Answer: A Hospice Physician's View (Totowa, NJ: Humana, 1992), p. 1; cf. K. Vaucrosson, "Doctors Lack Training in Hospice Care," Journal of the National Cancer Institute 84 (August 5, 1992), pp. 1153-4.

[11] This quote is from Quick Reference Guide for Clinicians, p. 6; cited in Life at Risk: A Chronicle of Euthanasia Trends in America 4 (April 1994), p. 4.

[12] D. Schiedermayer, M.D., "Oregon and the Death of Dignity," Christianity Today 39 (February 6, 1995), p. 18.

[13] Cundiff, Euthanasia Is Not The Answer, p. 70.

[14] Ibid., 106-7.

[15] A. B. Adams, M.D., "Dilemmas of Hospice: A Critical Look at its Problems," Hospice Care (New York: American Cancer Society, 1984), p. 15.

[16] S. A. Lack and R. W. Buckingham, III, First American Hospice: Three Years of Home Care (New Haven: Hospice, 1978).

[17] Cited by Stoddard, The Hospice Movement, p. 90.

[18] T. L. Goldfarb, "Hospice: Another Option for Terminal Illness," Medical Abstracts Newsletter 12 (September 1992), p. 1.

[19] See D. Kerr, "Mother Mary Aikenhead, the Irish Sisters of Charity and Our Lady's Hospice for the Dying," American Journal of Hospice & Palliative Care 10 (May-June 1993), pp. 13-20.

[20] D. Sadowski, "No One Dies Alone at Cleveland's Church-Based Malachi House," National Catholic Reporter 28 (October 1991), p. 12.

[21] See, e.g., M. Moore and L. C. Moore, "Yodogawa Christian Hospital: A Ministry to the Whole Person," Japanese Christian Quarterly 57 (1991), pp. 92-96.

[22] H. Mase, "Death and Dying: Towards an Ethic of Death," Currents in Theology and Mission 12 (1985), pp. 69-75.

[23] J. R. Machek, "Hospice: New Opportunity for Ministry," American Protestant Hospital Association Bulletin 43 (1979), pp. 63-67. P. E. Dixon, Hospice and Ministry (Nashville: Abingdon, 1988).

[24] R. S. Polk, "A Community Chaplaincy in Hospice Home Care," American Protestant Hospital Association Bulletin 44 (1980), pp. 31-34.

[25] E. Hayward, "The Chaplain's Role in Stress Management of Hospice Nurses," American Protestant Hospital Association Bulletin 45 (1981), pp. 86-89.

[26] Gates, "Where Is the Pastoral Counselor in the Hospice Movement?," Journal of Pastoral Care 41 (1987), p. 38.

[27] J. D. Williams, "The Hospice Movement: Convocation Address," Southwestern Journal of Theology 23 (1980), pp. 71-83.

[28] Cundiff, Euthanasia Is Not the Answer, p. 16.

[29] E. J. Emanuel and L. L. Emanuel ("The Economics of Dying: The Illusion of Cost Savings at the End of Life," The New England Journal of Medicine 330 [February 24, 1994], pp. 540-45) think the amount to be saved is at most 3.3% off the total national health care expenditure.

[30] A. Mitchell, et al., "Hospice Care: the Cheaper Alternative," Journal of the American Medical Association 271 (May 25, 1994), pp. 1576-77.

[31] Cundiff, Euthanasia Is Not the Answer, pp. 47-48.

[32] Z. S. Berry and J. Lynn, "Hospice Medicine," Journal of the American Medical Association 270 (July 14, 1993), p. 222.

[33] E. Butters, et al., "Assessing the Symptoms, Anxiety and Practical Needs of HIV/AIDS Patients Receiving Palliative Care," Quality of Life Research 1 (February 1992), pp. 47-51.

[34] T. M. Stephany, "AIDS Does Not Fit the Cancer Model of Hospice Care," American Journal of Hospice & Palliative Care 9 (January, February 1992), pp. 13-14; C. Tehan, "The Cost of Caring for Patients with HIV Infection in Hospice," Hospice Journal 7 (1991), pp. 41-59; J. P. Martin, "Issues in the Current Treatment of Hospice Patients with HIV Disease," Hospice Journal 7 (1991), pp. 31-40.

[35] N. T. Baker and R. D. Seager, "A Comparison of the Psychosocial Needs of Hospice Patients with AIDS and those with Other Diagnoses," Hospice Journal 7 (1991), pp. 61-69; D. N. Moga, et al., "AIDS in the Workplace: Implications for Hospice Programs," Hospice Journal 7 (1991), pp. 151-69.

[36] R. W. Buckingham, III, Among Friends: Hospice Care for the Person with AIDS (Buffalo: Prometheus, 1992), p. 70.