Too angry to die

Anger, especially in men, is really the other side of sadness, something we are not supposed to show openly. As Stan and the rest of us get older, some of our friends pass away or move out of state, our kids (if any) may or may not be involved in our lives, our ability to be productive (and physically active) may not be what it once was, and we become more and more isolated. Throw cancer into the mix, with the question of whether we can still live on our own terms. Stan has every right to be pissed!

The misunderstandings that swirl around "hospice" . . . Such a shame when, as you pointed out, the services available can be extensive. Watched a relative die of cancer without hospice last year and it was brutal and heartbreaking and so very unnecessary. It wasn't anger but denial that kept this person from getting help. And we could do nothing to convince otherwise.

First off, as me, I would agree with your assessment…based on the hospice philosophy of care Stan would be the ideal candidate for hospice and stands to gain much with the “right” care. But that wasn’t your question. Your question was asking if “I” was the intake nurse at Happy Hospice would I deem Stan to be hospice appropriate. That’s different and it would depend on several considerations. Some will not be to everyone’s liking but they are possible, plausible and realistic. Here are just a few. With hospice, being either a non-profit or for-profit business, I would have to know management’s policies on accepting patients. It would do Stan no good if I, as a compassionate nurse, accept him only to have the IDT, under orders from management, find a way to discharge him “for cause.” This is allowable under CMS’ Conditions of Participation, 2008 (Section 418.26, if you want to look it up) and varies by hospice. This section starts with (paraphrased) no patient, once accepted, can be discharged due to either being too costly or too time consuming. That’s good for Stan. He’s likely to be time consuming. But it continues that (paraphrased) CMS realizes that not all patients/conditions are appropriate for hospice (referring usually to violence, threats of physical harm, vicious animals, etc) and that each hospice can determine its own policy for discharge for cause. Happy Hospice might have a policy that doesn’t allow angry patients above a given threshold (that they decide). That’s bad for Stan. Some hospices might have a policy that angry patients must agree to sedation for their own safety as determined by the IDT RN or the hospice physician/medical director. Some hospices might do so even if patients don’t agree. This would be considered by some to be similar to Palliative Sedation and could involve the Doctrine of Double Effect. This could be equating intractable anger with intractable pain and, should he die from the sedation, not being culpable because their “intent” was to relieve pain, not cause death. If this were the case with Happy Hospice, I wouldn’t be working there and this, too, would not likely be favorable or acceptable to Stan. Now there is your statement that Stan “is not depressed, at least in the sense of being suicidal.” Yet, you later have Stan saying the ambiguous “if you can’t help me, well then I‘ll just do it myself.” I’m not sure if his reference is to help him die or relieve his pain. It would be critical for me as intake nurse to understand to which one Stan is referring. All hospices, by philosophy, reject assisted suicide. Some have stated policies about it; some not so much. I have an article from a national magazine about a person who claimed to have had the help of a hospice to grant her mother’s wish to speed her death through starvation. The mother felt death wasn’t coming soon enough. This would be stretching the hospice mantra about neither hastening death nor prolonging life a bit far by just standing idly by as she refused food. They did and she died. So I would need to know Happy Hospice’s policy on intervention in such matters as Stan doing whatever “it” is by himself. After I understood what he meant, of course. I suspect that either way this is probably not going on the plus side for Stan. Then we come down to the money. This is the back-biting going on in hospice today, generally between non-profits and for-profits…some, not all. Is the fiscal condition of Happy Hospice such that management is directing that any patient be accepted as long as they have a 6-month terminal prognosis certification? Does Happy Hospice “cherry pick” only the reasonably profitable patients and reject those historically likely to be unprofitable? Remember time is money, Stan will likely take considerable time and a good case must be made for discharging a patient that doesn’t make it appear to be based on any of the following: too costly, too time consuming or incurs suspicion of patient abandonment should anyone from either the State or CMS ever decide to review Stan’s file. If any of this were the case with Happy Hospice, I wouldn’t be talking to Stan because I wouldn’t be working there. Now I, as compassionate Happy Hospice intake nurse, would know these policies (and others) and would lay them out on the table along with reasonable expectations (both ways) for Stan to accept or reject. His answers, not my opinions except to the extent of Stan’s believability, would determine if he was a good fit for Happy Hospice. I would have to keep in mind that time is neither on Stan’s or Happy Hospice’s side. I’m assuming that further chemotherapy is futile and that Stan is a “let’s do it or not” type patient and would not be agreeable to any pre-anything counseling. I found it interesting that you said, “We enter the end of life, much as we have lived the rest.” I believe that each of Dame Cicely Saunders, Florence Wald and Elisabeth Kübler-Ross (all considered founders of the modern hospice movement) have said the same thing. Kübler-Ross said almost identical in her book, ‘On Death and Dying.’ I doubt that any of them ever rejected a patient for being angry no matter how extreme the anger. Kübler-Ross came up with the five stages of dying which includes anger. She acknowledged some people never move beyond it. Anger, of itself, should not be used as a reason to exclude someone from care.