For the past 11 years Garde Chessnoe a 55-year-old Annandale housewife has battled the cancer that now engulfs much of the right side of her body.
"We talk about my death. Mike and I, but we don't run it into the ground," said Chessnoe, an indomitable woman whose doctors told her she would be dead two years ago.
"I would not like to inflict the trauma of my dying on Mike," she continued, grinding out a cigarette and gazing calmly at her husband, Michael, a retired army colonel, "although there's a part of me that would very much like to stay in my own home. It takes a very strong, loving family to nurse a cancer patient to the end."
Where Chessnoe would like to die, she said is in a hospice, a facility geared to the needs of the dying, most of whom are cancer patients, and their families.
One of the newest concepts in medicine, hospices are controversial in some quarters. Critics of the concept say hospices are unnecessary and that cure can best be given in hospitals or nursing homes.
But hospices have won the endorsement of a wide variety of groups including the Arlington and D.C. medical societies, the American Cancer Society and the federally mandated health-planning agency, the Health Systems Agency of Northern Virginia.
"There's been an explosive growth of the hospice movement in the last few years," said Dr. John J. Lynch, chief of oncology (the study of tumors) at the Washington Hospital Center. "Who could argue with a place where dying get solace?" said Dr. Kenneth Haggerty, chairman of the board of Arlington Hospital. "It's kind of like being against motherhood."
"These days everybody wants to do hospice." said Richard Groppi, manager of health care planning for Blue Cross/Blue Shield.
Originally introduced in Britain a decade ago, there are two kinds of hospice care: home care and inpatient care. The idea of home care is that the patient dies at home, nursed by a loving family and visited at least weekly by a team of doctors, nurses and social workers.
When that is not possible because the patient has no relatives, because the patient cannot be controlled or because the family needs a respite from the emotional raveges of caring for a dying relative, the patient enters a hospice. The average stay is about three months.
The first hospice home care in the U.S. began four years ago in New Haven. The first inpatient hospice in the Washington area, a six-bed unit affiliated with Georgetown University, is scheduled to open July 31 at the Washington Home, 3720 Upton St. NW.
Hospice of Northern Virginia, a spinoff from the Georgetown project, began a home care program in March. According to the oncologist Dr. Josefina Magno, the Northern Virginia hospice hopes to open a 20-bed inpatient facility at Arlington's Woodlawn High School next summer. The school at 4720 N. 16th St. was closed last month because of declining enrollment.
A Virginia House of Delegates sub-Committee is presently holding public hearing on changes in state law necessary to license hospices. That subcommittee, according to chairman Mary Marshall (D-Arlington) plans to recommend new legislation to remedy the problem next January.
Absent from the hospices are the sterile white rooms, the starch hospital gowns and the sophisticated technology associated with life-saving care, which is the backbone of hospitals.
Patients are given whatever medi-
The goal of hospice care is to allow the patient to die in as happy and comfortable an environment as possible, with as much control as possible. The regimen is tailored to each patient. That may mean allowing children, friends and pets to visit at unconventional hours, or encouraging patients to bring with them cherished possessions, such as musical instruments, books, photographs.
Patients wear their own clothes and sleep in a cheerfullly decorated room with several others, in order to overcome the loneliness and terror that often accompanies dying alone in a clinical hospital environment.
The patient's death is acknowledged openly by the staff of doctors, nurses and therapist, who are available to the patient and his family around the clock.
"In a hospital we tend to pretend that people are going to get well," said Sister Mary Margaret Meldon, executive director of the Washington Hospice Society, which hopes to begin a home care program in January. "The main thing is to make it comfortable and homey. We don't want to make it a death house."
Hospice advocates and cancer patients like Chessnoe say one of the most important things about hospice care is that patients are given sufficiently large doses of addictive narcotics like morphine to enable them to relax and to die comfortably, rather than simply enduring their last few months in agony.
"I'm a nurse, so I have abilities other wives might not have," said Patricia Felker of Arlington whose husband Patrick, 42, has terminal liver cancer. "Many people are afraid to keep someone home, especially when the pain gets bad. Pain is a barrier to all other emotions."
At least once a week the Felkers, one of the 18 families who are patients of the Northern Virginia Hospice home care team, are visited by Dr. Magno, who has managed to bring Patrick Felker's pain under control.
Several weeks ago the Felkers, who have two teen-age children, decided they wanted Patrick, a former Interior Department analyst, to die at home. He checked out of the experimental cancer treatment unit at the National Institutes of Health, where had been a patient for 18 months since shortly after his cancer was first discovered during a routine physical exam.
"Gradually many of Pat's friends stopped coming," said his wife, a youthful-looking woman with streaked blonde hair. "I suppose it made them realize, 'Well, it could be me.' To be with Pat you have to admit he's dying. It's not like being with someone who doesn't know. There's no game-playing. I can't be absolutely comfortable even now."
Dr. Magno said hospices help surviving relatives like Patricia Felker come to terms with their grief, a process that takes about a year.
One of the critics of the hospice concept is Dr. Lloyd B. Burk Jr., an Arlington surgeon whose practice includes a large number of cancer patients.
Somebody's got to prove to me that they're needed," he said. "How are they different from nursing homes? I'm perfectly sympathetic with the cause they advocate: giving loving care to the terminally ill. That kind of care is given in hospitals."
"You can't ask somebody to walk into one hospital room and save lives and then go into another room and act differently," Dr. Lynch said. "I know that some nursing homes say they give hospice care. But nursing homes are geared to long-term chronic care. The kind of interaction with patients is very different. People die there but that's not really what nursing homes are for."
"The needs of the dying are unique," said Sarah Burger, a nurse, who is president of the Washington Hospice Society. "It's a very lonely process and in a big institution geared to cure you they obviously don't care for the dying. They're second class citizens."
"A lot of us fear McDonaldization of the hospice movement," Dr. Lynch said, as profit-making institutions seek to cash in on the trend. "I think many doctors are skeptical that hospice will work because of the resistance by insurance companies, medicare and medicaid to cover hospice care."
"The hospice concept is a good one," said Groppi. "But there's nothing to prevent these programs from unnecessarily duplicating themselves." He noted that blue Cross has agreed to cover the costs of subcribers who are referred to the Washington Home.
Hospice advocates say they view the Washington Home project as a bell-weather. If it is successful, they say they believe other insurance company will follow and Blue Cross may agree to cover the costs of the Hospice of Northern Virginia.
Estimates by the Health Systems Agency of Northern Viginia put the cost of inpatient hospice care at $83 a day, about twice the cost of nursing home care because of the larger staff. That figure is about half the cost of a hospital room because of the lack of sophisticated medical equipment. The cost of a home care visit is estimated to be $33.
The Arlington County Board has appropriate $225,000 toward the Arlington hospice and is awaiting remodelling estimates by an architect before final approval of the project. The hospice has receive unanimous endorsement by the civic association in the neighborhood of Woodlawn High School.
The county board has given preliminary approval to a law that would create an industrial authority that would have the power to finance a hospice.
Before a hospice can open in Arlington it must receive a certificate of need by the Health Systems Agency. "I think they have reason to be optimistic," executive director Dean Montgomery said. "The development of a hospice is a priority of the HSA's. What they have to do is submit a precise program and they could get a certificate within 90 days."