Monday

WAKING UP on Monday morning is always difficult. My 10-minute walk to work helps to ease the transition from grogginess to a semi-alert state.

Hospice Care of the District of Columbia gives medical, emotional and spiritual care to people who are dying in their own homes throughout the District. Our caregivers are on call 24 hours a day, seven days a week, and Monday morning is devoted to a team briefing, catching up on weekend events and the status of our patients.

Since I am neither doctor nor nurse, social worker nor clergy, my job is strictly administrative -- a source of considerable frustration. Luckily, a hallmark of Hospice Care is its nonhierarchical and multidisciplinary team approach. Thus everyone in the organization can be closely involved in planning and responding to our patients' needs.

Monday alternates between troubleshooting and long-term projects. The afternoon is interrupted by a call from a patient's friend needing to know how to obtain power of attorney. The patient is fast losing consciousness and his friend will need to be able to tie up his affairs. Since our social worker is out seeing other patients, I take the call and spend an hour checking with lawyers and the bank on how the patient's friend can manage his accounts. Time is of the essence but the bank seems unsympathetic to the urgency of the situation. When I call the patient's friend with the procedure she is filled with gratitude for the legwork I have done. Tuesday

The morning starts with the usual briefing. Our staff nurse is sick and we plan to cover the necessary nursing visits with volunteer nurses. Our 85 trained volunteers are an essential part of the program -- some supplementing our professional paid staff as nurses, social workers or clergy, others as lay visitors helping around the patient's house or talking and listening to patients and families, and still others working in the office and on committees.

Today, one of the volunteers is coming in to discuss a press release announcing our new name. Formerly the Washington Hospice Society, we have just adopted the name of Hospice Care of the District of Columbia. The transition is a slow one and each of us still gropes for the name when we answer the phone. We decide that the name change is not too newsworthy in itself, but our accomplishment of giving care for a full year is. We slant the press release accordingly.

At noon, I join our finance committee for a meeting to preview my report to the board of directors. We are spending within the limits of our budget, with the vast majority of resources being used for patient care. Since our support comes entirely from community donors I am conscious of the need to be accountable. The fact that we give care regardless of ability to pay necessitates a constant reserve of funds for caregiving.

Midafternoon brings the young daughter of a potential patient who needs to discuss the possibility of her mother's care. Her case is so compelling, yet so difficult -- our team has discussed for hours whether we could maintain her at home safely. Sometimes the most draining cases are those we don't take at all. Hospice should be the place to turn when all else fails. But the agonizing question of how to allocate our scarce resources means that some will go without. The daughter and her mother play on my conscience all afternoon and most of the evening. Wednesday

Every Wednesday begins with a support meeting for the caregivers with a psychiatrist. "Burnout" is a constant threat to those whose work constantly surrounds them with dying and death. Care for the caregivers is the only way to assure continued effectiveness.

After the support group we have the customary morning briefing. Our nurse is back on her feet and she and the social worker plan a full day of house calls. Our service area is the entire District, and often the most urgent visits are at the extreme corners of the city, meaning long travel times and lunches eaten in the car.

The beginning of a month following the end of a quarter means preparing numerous reports. My day is spent writing about June's activities for the board, finalizing a financial report and compiling endless demographic and service delivery data for District health officials. In the course of my calculations I confirm that our costs per visit are still very high, a fact that gives me added impetus to send off information requested by a potential funder.

Late in the afternoon I meet with our professional advisory committee whose job it is to make suggestions for maintaining our high-quality care. I am able to update them based on the reports I've been working on all day. They are also anxious to know that negotiations with Medicare are proceeding toward a contract for reimbursement.

A friend from New York is in town and we have a late dinner and several hours to talk. Thursday

After the morning briefing, my new administrative assistant and I embark on a reorganization of our files. In the process, I find myself reading the documents from our earliest history and marveling at how far we have come.

Unfiling and refiling lasts until early afternoon, leaving me just an hour to return morning calls before our patient planning meeting.

Three to 5 o'clock on Thursdays is reserved for planning meetings. The entire team assembles -- nurse, social worker, doctor, clergy and volunteers who are otherwise rarely in the office. We describe each case in detail and assess each patient's change over the week. Every member of the team contributes his observations, both about the patient and about members of the family. Notes are recorded for the patients' charts and an explicit plan is made for the care of each during the coming week. My job, principally, is to keep us on a schedule and to ask questions from the viewpoint of a non-caregiver. Since Hospice Care is concerned with the surviving family for as long as a year after the patient's death, part of our discussion today involves the support we are giving to a recent widow. Legal advice, we all agree, is one area in which we need to develop stronger contacts.

The briefing is briefer than usual this morning -- the caregivers are anxious to get on the road. I finish reports and correspondence that have been waiting all week. The part-time bookkeeper and I go over the System we are developing to give me more immediate access to our financial records.

At 2, the caregiving team convenes at my apartment for a meeting and critique. The caregivers have all been on the staff for about a year and a performance evaluation is in order. We decided earlier that self-assessment according to specific criteria would be the jumping-off point for a frank discussion of each member's strengths and shortcomings. The session is far more productive than I would have guessed. Each person is harsher on himself than warranted, but in the process, concrete suggestions are made on how the organization might run more effectively. The setting away from the office is an obvious asset -- three hours uninterrupted by telephone calls is an unheard-of luxury.

The evaluation session is not for my own assessment. But I take my turn describing how I feel about my performance. I have promised myself more time to visit with patients and the team agrees that I would gain from the experience.

The evening is spent with friends eating a Nepalese dinner, going to a movie and giving a tour of the monuments to a friend's visitor. Friday

Today begins with a phone call from the Hospice team coordinator of volunteers that there has been a death in her own family. She will be out of town all next week. We go through her week's schedule and I take notes on calls and cancellations to be made. We arrange for a volunteer to make the calls Monday and help set up volunteer assignments. Saturday

Saturday is always a day for catching up on chores and errands that have accumulated all week. I seem to hit the Safeway along with everyone else in the city and spend twice as long as I had intended. The weather is hot and muggy and by the time I get home I vow not to leave the air conditioning again.

My work has taught me the value of unscheduled time alone and I spend Saturday evening reading. Sunday

Sleeping late is a luxury I defend at all costs, but today I get up at the usual weekday time to go to the Kennedy Center. Tickets go on sale at noon today for the Berlin Ballet and I want to be in line before 9. I arrive in time to be among the first 20 or so in line. My vigil pays off when I am able to get good seats for the two ballet performances I want to see.

The weather today is perfect. I go to the park where I bump into a friend who had left Washington and now, a year later, has returned. In this city of transients, the direction is generally outbound, so his return is a real surprise.

Another friend from New York is in Washington this week and we attempt dinner. Washington must be the hardest place to have dinner late on Sunday. We finally settle on a place with outdoor seating where the waiter returns three times to tell us that the food we have ordered is no longer available.