Everyone Wants To Go To Heaven….

But Nobody Wants to Die

Jean Gordon RN, MSN, CHPNDirector of Education, QA/PI

Hospice of East Texas

ObjectivesObjectives

Identify evolving trends in end of life Identify evolving trends in end of life care, with a focus on palliative care .care, with a focus on palliative care .

Differentiate between hospice and Differentiate between hospice and palliative care programs. palliative care programs.

Dr. Atul Gawande – a surgeon and staff member of Dr. Atul Gawande – a surgeon and staff member of Brigham and Women’s Hospital and the Dana Farber Brigham and Women’s Hospital and the Dana Farber

Cancer Institute in BostonCancer Institute in Boston “Letting Go”, “Letting Go”, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

Our medical system is excellent at trying to Our medical system is excellent at trying to stave off death with chemotherapy, intensive stave off death with chemotherapy, intensive care, and surgery. But, ultimately, death comes, care, and surgery. But, ultimately, death comes, and no one is good at knowing and no one is good at knowing when to stopwhen to stop..

““In the past few decades, medical science has In the past few decades, medical science has created a new difficulty for mankind: created a new difficulty for mankind: how to diehow to die, ,

due to the seemingly unstoppable momentum of due to the seemingly unstoppable momentum of

medical treatment.” medical treatment.”

Do you want everything done?Do you want everything done?

What the patient/family hearsWhat the patient/family hears ResuscitationResuscitation VentilatorVentilator Surgery, transplants….Surgery, transplants…. Cure Cure Return to normal lifeReturn to normal life

What the physician/nurse meansWhat the physician/nurse means We’ll try CPR, if you insist.We’ll try CPR, if you insist.

Evolving RealitiesEvolving Realities

Life expectancy has increasedLife expectancy has increased Increased prevalence of chronic diseaseIncreased prevalence of chronic disease Increased comorbidities and frailty with Increased comorbidities and frailty with

advancing age adding to complexityadvancing age adding to complexity

Death is considered by many -- Death is considered by many --

to be “to be “optionaloptional””

25% of all Medicare spending 25% of all Medicare spending is for 5% of patients who are is for 5% of patients who are in their final year of life; in their final year of life;

and most of that money goes and most of that money goes for care in their last couple of for care in their last couple of months….months….

which is of little apparent which is of little apparent benefit.benefit.

Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

Finley, E. & Casarett, D. (2009). Making Finley, E. & Casarett, D. (2009). Making Difficult Discussions Easier: Using Prognosis Difficult Discussions Easier: Using Prognosis

to Facilitate Transitions to Hospice. to Facilitate Transitions to Hospice. CA CA Cancer J ClinCancer J Clin

What Do Patients Want??What Do Patients Want?? Realistic prognostic informationRealistic prognostic information Straightforward communicationStraightforward communication Time and ability to ask questionsTime and ability to ask questions Sensitivity, empathy, & “expertise”Sensitivity, empathy, & “expertise” Assurance of non-abandonmentAssurance of non-abandonment Appropriate transition to palliative careAppropriate transition to palliative care

ChallengesChallenges Difficulty with patients and/or families accepting Difficulty with patients and/or families accepting

that effective treatment is no longer availablethat effective treatment is no longer available Or… that patient has fewer than 6 months to live.Or… that patient has fewer than 6 months to live. Certain people have the skills to cope well and go Certain people have the skills to cope well and go

gently into the night, while many never come to gently into the night, while many never come to terms with the fact that they are dying.terms with the fact that they are dying.

Some understand that death is imminent but Some understand that death is imminent but aren’t emotionally accepting of it and fight to stay aren’t emotionally accepting of it and fight to stay alive at any cost.alive at any cost.

Casarett, D. & Quill, T. (2007). “I'm Not Ready for Hospice": Strategies for Timely Casarett, D. & Quill, T. (2007). “I'm Not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions. and Effective Hospice Discussions. Annals of Internal Medicine. 146Annals of Internal Medicine. 146 (6). (6).

““What should medicine do What should medicine do when it can’t save your life?”when it can’t save your life?”

““Modern medicine is good at staving Modern medicine is good at staving off death with aggressive interventions off death with aggressive interventions --

and bad at knowing when to focus, and bad at knowing when to focus, instead, instead,

on improving the days that terminal on improving the days that terminal patients have left.” patients have left.”

Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

““How can we build a health-care How can we build a health-care system that will actually help system that will actually help dying patients achieve what’s dying patients achieve what’s most important to them at the most important to them at the end of their lives.”end of their lives.”

Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

Restoring the BalanceRestoring the Balance

Life Prolonging Care

Palliative Care

Trends in End of Life CareTrends in End of Life Care

Greater emphasis on ‘reasonable’ Greater emphasis on ‘reasonable’ care through:care through:

1.1. New legislationNew legislation

2.2. ‘‘AND’ ordersAND’ orders

3.3. Palliative care teams/servicesPalliative care teams/services

The Palliative Care Information Act bill The Palliative Care Information Act bill (S. 4498 Duane/ A. 7617 Gottfried), has (S. 4498 Duane/ A. 7617 Gottfried), has passed both houses of the NY State passed both houses of the NY State legislature and is awaiting signature by legislature and is awaiting signature by New York’s Governor David Paterson. If New York’s Governor David Paterson. If signed, the bill “requires physicians to signed, the bill “requires physicians to discuss all end of life options.” discuss all end of life options.”

http://www.examiner.com/x-59793-NY-Healthy-Living-http://www.examiner.com/x-59793-NY-Healthy-Living-Examiner~y2010m7d30-NY-Governor-considers-law-to-prompt-Examiner~y2010m7d30-NY-Governor-considers-law-to-prompt-discussions-about-end-of-life-decisions?cid=email-this-articlediscussions-about-end-of-life-decisions?cid=email-this-article

The health reform bill that passed April, The health reform bill that passed April, 2010 included a Medicare pilot project 2010 included a Medicare pilot project to allow 12 communities across the to allow 12 communities across the country to offer both country to offer both curative curative treatmenttreatment and and hospice serviceshospice services to to terminal patients to evaluate whether terminal patients to evaluate whether physicians would refer earlier and physicians would refer earlier and patients would accept hospice earlier.patients would accept hospice earlier.

Supportive Versus Palliative Care: Supportive Versus Palliative Care: What's in a Name?What's in a Name?

Palliative CarePalliative Care as a term was seen as as a term was seen as more distressing to providers, patients, more distressing to providers, patients, and families than and families than Supportive CareSupportive Care and and perceived as synonymous with hospice perceived as synonymous with hospice and with giving up hope. and with giving up hope.

TreatmentTreatment implies that something active implies that something active will be done and that there is still hope,will be done and that there is still hope,

whereas whereas carecare is viewed as less active and is viewed as less active and devoid of hope. devoid of hope.

Fadul N, Elsayem A, Palmer JL, et al. (2009). Supportive versus palliative care: what's in a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer.

Supportive Versus Palliative Care: Supportive Versus Palliative Care: What's in a Name?What's in a Name?

Many use the phrase "the patient has been Many use the phrase "the patient has been taken off treatment" when chemotherapy has taken off treatment" when chemotherapy has been discontinued,been discontinued,

despite the fact that opioids are being titrated, despite the fact that opioids are being titrated, medications are given for symptom medications are given for symptom management, and family needs are being management, and family needs are being addressed. addressed.

This is the provision of supportive or palliative This is the provision of supportive or palliative treatmenttreatment. .

Fadul N, Elsayem A, Palmer JL, et al. (2009). Fadul N, Elsayem A, Palmer JL, et al. (2009). Supportive versus palliative care: what's in Supportive versus palliative care: what's in a name? A survey of medical oncologists and midlevel providers at a comprehensive a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. cancer center. CancerCancer. .

Supportive Versus Palliative Care: Supportive Versus Palliative Care: What's in a Name?What's in a Name?

When patients are given a choice between When patients are given a choice between pursuing non-evidence based, unproven life-pursuing non-evidence based, unproven life-prolonging interventions prolonging interventions (frequently called (frequently called treatments),treatments), or or

receiving only Palliative Care, receiving only Palliative Care, they might opt for treatment only because they might opt for treatment only because they they

view any treatment as preferable to care.view any treatment as preferable to care.

Fadul N, Elsayem A, Palmer JL, et al. (2009). Fadul N, Elsayem A, Palmer JL, et al. (2009). Supportive versus palliative care: what's in Supportive versus palliative care: what's in a name? A survey of medical oncologists and midlevel providers at a comprehensive a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. cancer center. CancerCancer. .

Supportive Versus Palliative Care: Supportive Versus Palliative Care: What's in a Name?What's in a Name?

Physicians & patients are more Physicians & patients are more responsive toresponsive to “hospice treatment”“hospice treatment” rather than end of life care.rather than end of life care.

Fadul N, Elsayem A, Palmer JL, et al. (2009). Fadul N, Elsayem A, Palmer JL, et al. (2009). Supportive versus palliative care: Supportive versus palliative care: what's in a name? A survey of medical oncologists and midlevel providers at what's in a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. a comprehensive cancer center. CancerCancer. .

A.N.D. (Allow Natural Death)A.N.D. (Allow Natural Death)

““If your heart stops, we are going to let If your heart stops, we are going to let you die peacefully.”you die peacefully.”

““We will give you medicines to help make We will give you medicines to help make your breathing more comfortable.”your breathing more comfortable.”

These phrases truthfully communicate These phrases truthfully communicate the care that clinicians have and prevents the care that clinicians have and prevents the patient/caregiver from feeling that the patient/caregiver from feeling that ‘care has been withdrawn’‘care has been withdrawn’

A.N.D. orders vs A.N.D. orders vs D.N.R. D.N.R. ordersorders

Perceptions can be everything -Perceptions can be everything - PositivePositive SupportiveSupportive Non-abandonmentNon-abandonment EmpathyEmpathy

Palliative CarePalliative Care

an approach to care that improves an approach to care that improves quality of life of patients and their quality of life of patients and their families facing life-families facing life-threatening illness, through prevention, threatening illness, through prevention, assessment, and treatment of pain and assessment, and treatment of pain and other physical, psychological, and other physical, psychological, and spiritual problems.spiritual problems.

(WHO, 1982)(WHO, 1982)

Palliative Care:Palliative Care: Supports the patient and family’s Supports the patient and family’s

goals for the future, during whatever goals for the future, during whatever time they have remainingtime they have remaining

as well as their hopes for peace and as well as their hopes for peace and dignity throughout the dignity throughout the course of course of illnessillness, the dying process, and death. , the dying process, and death.

Prevents and relieves suffering and Prevents and relieves suffering and promotes the best possible quality of promotes the best possible quality of lifelife

American Academy of Hospice and Palliative MedicineAmerican Academy of Hospice and Palliative Medicine

How do you attend to the How do you attend to the thoughts and concerns of the thoughts and concerns of the dying when medicine has made dying when medicine has made it almost impossible to be sure it almost impossible to be sure who the dying even are? who the dying even are?

Is someone with terminal cancer, Is someone with terminal cancer, dementia, or incurable dementia, or incurable congestive heart failure dying, congestive heart failure dying, exactly?exactly?

Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

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20

40

60

80

100

120

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CANCER

CHF

DEMENTIA

COPD

Prognosis Can Be Difficult to PredictPrognosis Can Be Difficult to PredictLife Shortening Illness Actively DyingLife Shortening Illness Actively Dying

Potential Goals of CarePotential Goals of Care Cure of diseaseCure of disease Avoidance of Avoidance of

premature deathpremature death Maintenance or Maintenance or

improvement in improvement in functionfunction

Prolong lifeProlong life

Relief of sufferingRelief of suffering Quality of lifeQuality of life Staying in controlStaying in control A good deathA good death Support for Support for

families and families and loved onesloved ones

Palliative Care’s Place in the Course of IllnessPalliative Care’s Place in the Course of Illness

Life Prolonging Therapy

Palliative Care

MedicareHospiceBenefit

DEATH

Diagnosis of SeriousIllness

Palliative CarePalliative Care

Focuses on the patient and family Focuses on the patient and family preferences, not just on the patient’s preferences, not just on the patient’s disease process.disease process.

Seriously ill people often feel as Seriously ill people often feel as though they are lost among many though they are lost among many specialists focused on specialists focused on body organs.body organs.

> 5800 hospitals in the US – 2009> 5800 hospitals in the US – 2009 Over 1300 hospitals have palliative Over 1300 hospitals have palliative

care programs.care programs. Palliative Care Services reduce Palliative Care Services reduce

hospital cost and length of stay;hospital cost and length of stay; reduce utilization of critical care reduce utilization of critical care

beds;beds; improve care of patients near end of improve care of patients near end of

life; life; optimize symptom management.optimize symptom management.

What Is Hospice?What Is Hospice? A program for patients who have a A program for patients who have a

limited prognosis or life expectancy – limited prognosis or life expectancy – Usually, 6 months or lessUsually, 6 months or less Goals:Goals:

Relief of pain and other symptomsRelief of pain and other symptoms Psycho-social supportPsycho-social support

Benefit covered by medicare, Benefit covered by medicare, medicaid, and most insurance medicaid, and most insurance companies at no cost to the patient.companies at no cost to the patient.

Regular visits by nurse, hospice aide, Regular visits by nurse, hospice aide, & social worker to allow family to care & social worker to allow family to care for patient at homefor patient at home

Volunteers, clergy – as desired Volunteers, clergy – as desired Medications to manage pain and Medications to manage pain and

symptoms related to the terminal symptoms related to the terminal diagnosisdiagnosis

Supplies, medical equipment, 24 hour Supplies, medical equipment, 24 hour RN and physician availabilityRN and physician availability

Hospice provides:Hospice provides:

Hospice does not Hospice does not == morphine drip,morphine drip, or or giving upgiving up

Dr. Atul GawandeDr. Atul Gawande – surgeon and staff member of – surgeon and staff member of Brigham and Women’s Hospital and Brigham and Women’s Hospital and

the Dana Farber Cancer Institute in Bostonthe Dana Farber Cancer Institute in Boston “Letting Go”, “Letting Go”, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

““Like many people, I had Like many people, I had believed that hospice care believed that hospice care hastens death, because patients hastens death, because patients forgo hospital treatments and forgo hospital treatments and are allowed high-dose narcotics are allowed high-dose narcotics to combat pain.”to combat pain.”

HospiceHospice But studies suggest otherwise. But studies suggest otherwise. A study of 4,493 Medicare patients with A study of 4,493 Medicare patients with

either terminal cancer or congestive either terminal cancer or congestive heart failure, found no difference in heart failure, found no difference in survival time between hospice and non-survival time between hospice and non-hospice patients withhospice patients with

breast cancer, breast cancer, prostate cancer, and prostate cancer, and colon cancer. colon cancer. Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

HospiceHospice Curiously, hospice care seemed to Curiously, hospice care seemed to

extend survival for some patients; extend survival for some patients; those with pancreatic cancer gained those with pancreatic cancer gained

an average of three weeks, an average of three weeks, those with lung cancer gained six those with lung cancer gained six

weeks, & weeks, & those with congestive heart failure those with congestive heart failure

gained three months. gained three months.

Atul Gawande MD, Atul Gawande MD, The New Yorker, August, 2, 2010The New Yorker, August, 2, 2010

Hospice care goes where the patient is Hospice care goes where the patient is – home, assisted living, nursing home, – home, assisted living, nursing home, inpatient unitinpatient unit

80% of hospice care takes place in the 80% of hospice care takes place in the homehome

An RN case manager is assigned to An RN case manager is assigned to each patient to coordinate care and each patient to coordinate care and follow the patient’s and family’s goals follow the patient’s and family’s goals for end of life.for end of life.

Hospice Care Hospice Care Provides:Provides:

Patient & family control over decisions about Patient & family control over decisions about carecare

Anticipation of disease progression and Anticipation of disease progression and preparation for patient declinepreparation for patient decline

Short term inpatient care for crises or respiteShort term inpatient care for crises or respite Option for patient to die at home & be Option for patient to die at home & be

pronounced by an RN (without calling 911)pronounced by an RN (without calling 911) Grief counseling for 1 year following patient’s Grief counseling for 1 year following patient’s

deathdeath

Conditions for Hospice Conditions for Hospice Eligibility Under MedicareEligibility Under Medicare

Order for certification of terminal illness Order for certification of terminal illness and admission to hospice by and admission to hospice by patient’s attending physician and Hospice Medical patient’s attending physician and Hospice Medical DirectorDirector

Patient chooses hospice benefits rather than Patient chooses hospice benefits rather than standard Medicarestandard Medicare**

Patient chooses palliation as goal, rather than curePatient chooses palliation as goal, rather than cure Under Medicare, DNR status Under Medicare, DNR status cannotcannot be used as a be used as a

requirement for admissionrequirement for admission

*Patient may choose to revoke Hospice Care and *Patient may choose to revoke Hospice Care and revert to Cure-Oriented Care at any timerevert to Cure-Oriented Care at any time

Diseases with Coverage GuidelinesDiseases with Coverage Guidelines indications of terminalityindications of terminality

Liver diseaseLiver disease Renal diseaseRenal disease ALS disease ALS disease

(Amyotrophic Lateral (Amyotrophic Lateral Sclerosis; Lou Sclerosis; Lou Gehrig's Disease )Gehrig's Disease )

HIV diseaseHIV disease

Heart diseaseHeart disease Alzheimers & Alzheimers &

dementiadementia Pulmonary diseasePulmonary disease Stroke and/or comaStroke and/or coma Adult failure to Adult failure to

thrivethrive Neurologic Neurologic

disordersdisorders Medicare requires recertification every 60 days to Medicare requires recertification every 60 days to assess and document continued appropriateness assess and document continued appropriateness for the hospice benefit.for the hospice benefit.

Benefits of Hospice CareBenefits of Hospice Care

Interdisciplinary, collaborativeInterdisciplinary, collaborative Cost-effective Cost-effective Extremely high patient and family Extremely high patient and family

satisfactionsatisfaction Improves quality of lifeImproves quality of life Patients can revoke to pursue Patients can revoke to pursue

treatment or testing and then readmit, treatment or testing and then readmit, if desiredif desired

Comparing Comparing Hospice vs. Palliative CareHospice vs. Palliative Care

Hospice ServicesHospice Services Patient population Patient population Patients with life-Patients with life-

limiting illness; 6 limiting illness; 6 months or lessmonths or less

Sites of careSites of care • Home, NF, Assisted Home, NF, Assisted

living, hospital, hospice living, hospital, hospice inpatient unitinpatient unit

Hospital-Based Hospital-Based Palliative Care Palliative Care ServicesServices

Patients at any stage of Patients at any stage of advanced or life-limitingadvanced or life-limiting

illness; illness; May continue with May continue with

curative treatmentscurative treatments

Hospital;Hospital;• outpatient or NF services outpatient or NF services

varies by program varies by program - no home care services- no home care services

Comparing Comparing Hospice vs. Palliative CareHospice vs. Palliative Care

Hospice ServicesHospice Services Pain & symptom Pain & symptom

management, management, psychosocial, psychosocial, volunteer, spiritual, volunteer, spiritual, bereavement supportbereavement support

Coordinated care Coordinated care delivered by IDT delivered by IDT (physician, nurse, SW, (physician, nurse, SW, clergy, aide, clergy, aide, volunteer, pharmacist, volunteer, pharmacist, therapist)therapist)

Hospital-Based Palliative Hospital-Based Palliative Care ServiceCare Service

Pain & symptom Pain & symptom managementmanagement

Services vary by Services vary by program from a program from a single MD to NP, SW, single MD to NP, SW, nurse, clergy, nurse, clergy, psychologist, psychologist, counselors, therapycounselors, therapy

Comparing Comparing Hospice vs. Palliative CareHospice vs. Palliative Care

Hospice ServicesHospice Services Program reimbursed Program reimbursed

by medicare, by medicare, medicaid, insurancemedicaid, insurance

Medications, supplies, Medications, supplies, durable medical durable medical equipment – provided equipment – provided at no cost to patientat no cost to patient

Family bereavement Family bereavement support for 1 year support for 1 year after deathafter death

Palliative Care ServicesPalliative Care Services Physician consult is Physician consult is

paidpaid All other services are All other services are

non-reimbursednon-reimbursed

Texas Palliative Care (TPC)Texas Palliative Care (TPC)

The only palliative care service in east TexasThe only palliative care service in east Texas Service began October, 2008 and is offered Service began October, 2008 and is offered

at Mother Frances Hospital and ETMC in at Mother Frances Hospital and ETMC in TylerTyler

Dr. Laura Ferguson, Dr. Thomas Beets, Dr. Dr. Laura Ferguson, Dr. Thomas Beets, Dr. Keith Frazier, Dr. Craig Gunter – all board Keith Frazier, Dr. Craig Gunter – all board certified in Hospice and Palliative Medicinecertified in Hospice and Palliative Medicine

80 new consults/month in hospital (roughly 80 new consults/month in hospital (roughly 3/day)3/day)

HOET part-time RN, HOET part-time RN, hospitahospital social work and l social work and clergyclergy

½ day clinic twice monthly (4 – 5 patients)½ day clinic twice monthly (4 – 5 patients) primarily pain management primarily pain management

Texas Palliative Care (TPC)Texas Palliative Care (TPC)

Hospital consultsHospital consults1.1. ““having the talk”having the talk”2.2. concerns R/T life support concerns R/T life support

(withholding or withdrawing)(withholding or withdrawing)3.3. medical futility, family insistence on medical futility, family insistence on

care, family disagreementcare, family disagreement4.4. pain and symptom managementpain and symptom management5.5. medical evaluation regarding medical evaluation regarding

patient capacitypatient capacity

TPC Hospital ConsultsTPC Hospital Consults 30-40%30-40% - 1 time consult resulting in - 1 time consult resulting in

agreement on withdrawal of life support agreement on withdrawal of life support (resulting in death or transfer to hospice)(resulting in death or transfer to hospice)

30–40%30–40% - multiple MD or RN visits to - multiple MD or RN visits to discuss options, answer questions, provide discuss options, answer questions, provide emotional and psychosocial support -emotional and psychosocial support -resulting in death or transfer to hospiceresulting in death or transfer to hospice

15-20%15-20% - multiple MD or RN visits resulting - multiple MD or RN visits resulting in transfer to skilled care (home health, in transfer to skilled care (home health, nursing facility, rehab, or aggressive care)nursing facility, rehab, or aggressive care)

2%2% - strictly pain and symptom - strictly pain and symptom management; followed in clinicmanagement; followed in clinic

TPC benefitsTPC benefits Rate of hospital readmission has

declined significantly on all patients consulted

Decreased length of hospital stay, especially critical care

+ 50% of all consults enroll in a hospice program (reinforces the (reinforces the skill needed for end of life skill needed for end of life prognostication)prognostication)

Coping with Cancer StudyCoping with Cancer StudyNCI and Dana-Farber Cancer Institute NCI and Dana-Farber Cancer Institute

October 2008October 2008

Patients who recalled having end of life talks Patients who recalled having end of life talks with their physicians:with their physicians:

were more likely to accept that their illness was were more likely to accept that their illness was terminal; terminal;

preferred comfort care over life-extending preferred comfort care over life-extending therapies;therapies;

received less aggressive medical treatment, received less aggressive medical treatment, such as resuscitation or admission to an such as resuscitation or admission to an intensive care unit;intensive care unit;

and enrolled earlier in hospice programsand enrolled earlier in hospice programs. .

Coping with Cancer StudyCoping with Cancer Study

More aggressive medical care was More aggressive medical care was associated with worse patient quality associated with worse patient quality of life and worse adjustment by of life and worse adjustment by patients' bereaved caregivers. patients' bereaved caregivers.

Moreover, 6 months after the patients Moreover, 6 months after the patients died, died,

their family members were much less their family members were much less likely to experience persistent major likely to experience persistent major depression.depression.

Excerpts from HOET family Excerpts from HOET family interviewsinterviews

““When the doctor told us it was time for When the doctor told us it was time for hospice, I was surprised.”hospice, I was surprised.”

““I don’t know what I expected… I don’t know what I expected… that at the end, we would that at the end, we would just disappear and just disappear and arrive in heaven….arrive in heaven….

I never thought about it.”I never thought about it.”

Our every impulse Our every impulse is to fight…. is to fight….

and we want and we want choices, but, choices, but,

Hope is not a plan.Hope is not a plan.

Everyone Wants To Go To Everyone Wants To Go To Heaven….Heaven….

But Nobody Wants to DieBut Nobody Wants to Die