Hospice Patients Alliance: Consumer Advocates


Intentional Medical Killings in US Hospices:
Has Anyone Seriously Addressed the Issue?



Serious Problem of Involuntary Medical Killings Is Real

We have provided in addition to accounts of commonly known violations of standards of care, four accounts (and many others on other pages) of medical killings of a patient in hospices in various locations in the United States:

Involuntary Euthanasia Case 1
Lucid, Poor, Elderly Veteran Euthanized Against His Will

Involuntary Euthanasia Case 2
HMO Commits Medicare Fraud, Kills Patient and Falsifies Death Certificate

Involuntary Euthanasia Case 3
Hospice Kills Family's Mother with Morphine Overdose

Involuntary Euthanasia Case 4
Hospice Kills Parkinson's Patient by Dehydration, Terminal Sedation
and Morphine Overdose

These reports have been gone over, detail by detail with the families who reported them. In every case, the details have never changed and the story told remains the same: they all report, "my father/mother was medically killed (euthanized) totally against his or her conscious will, even though they were competent and protesting as long as they could. They all eventually became comatose and subsequently died after 1)the administation of either a) sedatives b) narcotics, c) both sedatives and narcotics or 2) the direct refusal of the hospice staff to allow treatment for infection when the patient was not DNR and the family begged for treatment to be given. Some of these patients were not terminal at all, but rather chronically ill but stable - due to disease processes, or chronically ill due to medical malpractice and/or negligence.

We have received other complaints about similar medical killings, however these four families have agreed to allow their stories to be publicly told. The details may vary, but it is clear that these deaths were not voluntary and not natural in their timing. That is to say, the normal hospice process allows for a death in its own time, while providing a full range of services to alleviate distressing symptoms and especially pain. None of the four cases involved patients with serious pain issues, and none of them were cancer patients. None of the patients expressed wish to either refuse a medication (or get a medication for infection) was honored by the hospice staff and management.

Safeguards Already In Place Do Not Prevent Medical Killings

Some argue that "safeguards must be put in place to prevent these types of tragedies." However, laws already provide for the right of a patient to refuse to be treated or to accept treatment. Laws and regulations already exist that forbid non-terminal chronically ill patients from being enrolled in hospice. Laws already exist that forbid a patient from being "kidnapped" and forced into a hospice against his expressed wish. Regulations and laws exist to forbid the injection of a patient (against his will) with a medication that he is known to be severely allergic to, having had previous serious adverse reactions.

Safeguards And Regulations Disregarded

The intent of a rogue HMO and/or hospice, or of a family member may result in the pushing aside of the normal constraints and protections envisioned by laws and regulations. It is evident from the four cases presented, a family member may conspire with hospice staff to hasten a patient's death and other family members may have little ability to prevent the medical killing of their loved one: this, even when the patient himself is refusing medications which would soon lead to his untimely death or when the patient and family both request needed treatment for infection which left untreated would lead to an untimely death.

It is evident from research conducted both in the state of Oregon, USA and in the Nethlands, that even where euthanasia is legalized, in the majority of cases, all safeguards are not followed. See:

  1. Regulating Death - Euthanasia and the case of the Netherlands by Carlos Gomez, MD;
  2. Seduced by Death - Doctors, Patients and the Dutch Cure by Herbert Hendin, MD;
  3. JAMA 1998 and search from the JAMA site for the following article: Aug 12;280(6):507-13 entitled "The practice of euthanasia and physician-assisted suicide in the United States: adherence to proposed safeguards and effects on physicians." written by Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR done at the Center for Outcomes and Policy Research, Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, Mass 02115, USA;
  4. Archives of Internal Medicine Vol. 160 No. 1, January 10, 2000, "Attitudes and Practices Concerning the End of Life - A Comparison Between Physicians From the United States and From the Netherlands" (by Dick L. Willems, MD, PhD; Elisabeth R. Daniels; Gerrit van der Wal, PhD; Paul J. van der Maas, PhD; Ezekiel J. Emanuel, PhD.

Some HMOs or hospices are, in some cases, acting in a manner which results in an untimely death for the patient, contrary to the safeguards and regulations in place. There is nothing in the hospice regulations that allow for a non-terminal patient to be enrolled in the hospice. There is nothing in the regulations that allow for a non-terminal patient who happens to be in the hospice, to be denied treatment for infection. There is nothing in the regulations that allow for the administration of sedatives and/or narcotics when the patient has no medical need, no pain, no restlessness, anxiety and/or agitation.

When narcotics and/or sedatives are administered to an unwilling patient where there is no symptom to be alleviated, the administration of the sedative and/or narcotic is a violation of the patient's human rights, patient rights and a direct battery against the patient. Where it results in an untimely death, such administration of sedatives and/or narcotics to an unwilling patient equals an involuntary euthanasia ... a medical killing.

It may be debated whether the physician, nurse or other staff member is conscious or aware of the probable results of his or her actions. In some situations, a nurse, staff member or family member may be ignorant of the tremendous power of these medications and simply lump all patients together and give these medications when they are not indicated. Others may be quite conscious of the effect of the medications and intend, very clearly to euthanize the patient, in the belief that the patient would be better off dead than alive.

Most increases in dosage for a narcotic and/or sedative are ordered on a PRN basis, which means, "give as needed," rather than "give no matter what." Physicians may specify a specific dosage of narcotic, given at specific intervals, for relief of pain, and allow for an increase if the pain is not managed. There is no provision for increasing the dosage of a patient's medication where no symptoms warrant such an increase. Increasing the dosage of such powerful sedatives and narcotics, in the absence of uncontrolled symptoms, is a certain path to realization of the most serious adverse effects of the medications involved: with sedatives - coma, dehydration and death if continued longterm; with narcotics - coma, dehydration, respiratory depression and death if continued.

Nurse Licensure and Training Makes Nurse Liable for Actions

That nurses are not liable for what a physician orders, is simply not accurate. The health care regulations envision a "check and balance" approach to the administration of treatments and medications. The physician is licensed to give medical orders, however a nurse is responsible to evaluate the orders, to the best of her ability, before following such medical orders. If a nurse believes that based upon the patient's clinical situation presenting at the time, that the medical orders are not appropriate, she has not only the right, but the responsibility, to hold the treatment or medication and immediately request clarification and feedback from the physician and/or a supervising nurse above her in the "chain of command." If the nurse fails to report a problem and goes ahead in administering a treatment and/or medication which is inappropriate given the patient's current clinical status, the nurse is liable for the consequences.

Nurses are licensed just the same as physicians are. Nurse training and responsibility include: knowing the effects of medications given, knowing the adverse effects of medications given, knowing what is the appropriate situation for administering a medication, and calling the physician for direct clarification and medical orders when there is any doubt about the situation. Even in hospice where standing orders are quite commonly used, the need to call the physician for clarification and medical orders is quite clear and not in question at all.

Hospice Setting Makes Nurse, Physician and Hospice
More Liable Rather Than Less Liable

It can be argued that in the hospice setting, a nurse or hospice may actually be more liable for the medical killing of a patient (compared to clinic, hospital or nursing home settings where a physician may be more readily available on site), because in almost all situations, the physician is not on the scene at all! Hospice has been created as a way of relieving physicians of the need for a myriad of interventions related to the care of the dying. Patient conditions change quickly when a true terminal condition exists. For that reason, standing orders are set in place to provide needed medications which may alleviate severe distressing symptoms, even without contacting the physician in the moment. There is a great degree of "trust" placed in the hospice RN case manager and other licensed nurses who assess and/or attend to the patient at the bedside.

In the case of a terminally ill patient, the physician has stated that in his medical opinion, curative treatment would be ineffective and management of symptoms is the best and most humane course of medical care. These physicians often have demanding medical practice obligations which prevent them from attending to the patient's changing clinical status. The physician relies upon the report of the hospice RN case manager for an accurate clinical patient assessment. The physician then bases his orders upon the nurse's report. This system works well in many cases and the patient's symptoms are relieved with appropriate and timely hospice intervention.

In the scenario where a hospice nurse has an agenda of mercy killing and sees herself as the agent of relief for a suffering patient, the nurse may not accurately report the patient's clinical status to the physician! The medical record may be falsely entered to show pain where there was no pain, agitation where there was no need for a sedative. With nobody on site to supervise the nurse's actions, great integrity is required to assure appropriate intervention. A vast majority of hospice workers are dedictated and have great integrity, but where the nurse is of the other sort, how is a patient to be protected?

If you believe that a physician has seriously violated medical ethics and the standards of care, even to the point of performing an involuntary euthanasia, you can file a complaint with the State Medical Board. If you believe a nurse has seriously violated nursing ethics and the standards of care, even to the point of performing an involuntary euthanasia, you can file a complaint to the State Board of Nursing.

Most county district attorneys and federal prosecutors will want to see the determination of the state medical or nursing board before going ahead with a prosecution. Filing a prompt complaint to these medical or nursing boards will speed up the process to get a prosecution for medical killing. Remember that government moves very slowly, so filing a carefully stated and complete complaint with these boards as soon as possible is important. You may wish to consult with an attorney before filing a complaint to these boards, so that your complaint is properly worded and complete.

Family Role In Involuntary Euthanasia/Medical Killings

According to both Herbert Hendin, MD and Carlos Gomez, MD the role of the family in medical killings of patients cannot be disregarded. In fact, both mention the actual involvement of other family members in the decision-making process. Where the patient is conscious, competent and not at the natural "active phase of dying," they mention that a coercive effect may result from family, friends and the physician involved. They mention that in some circumstances, when a physician discusses the option of euthanasia, a family member commonly speaks for the patient, in the same room, even though the patient is conscious and able to speak for themselves. It appears that the patient is disregarded in deference to a perhaps domineering family member who is intent upon the euthanasia of the ailing patient.

What psychological dynamics are at play during such discussions would make for heated debate among psychiatrists, psychologists, social workers and physicians. There can be many reasons a family member may wish the patient dead:

Where the hospice fails to provide adequate nursing coverage to see to the needs of the patient, accurate and timely assessment of the patient's clinical status may not be realized. In many cases, families report a total unresponsiveness of a hospice to urgent calls from the patient and/or family to the hospice. Total unresponsiveness has been reported to last as long as a day or more. This unresponsiveness is defined as a failure to send a nurse out to the home, failure to request and obtain needed medications, and in many cases, a failure to even call back to discuss the urgent call from the patient and/or family

For these families, the unresponsiveness of the hospice may trigger a call to Emergency Medical Services for a transfer of the patient to a nearby hospital, where care may or may not be appropriate for the terminally ill patient. In some cases, when a hospice fails to intervene in a timely and appropriate manner, the family may find temptation too great: with potent sedatives and/or narcotics readily available at bedside, the family may simply increase the administered dosage of sedative or narcotic as a quick and easy solution to managing the distress of the patient and relieving the burden placed upon the family by having to deal with the sometimes overwhelming patient care needs.

What role the failure of hospices to provide timely intervention (in a time of patient symptom crisis) plays in the frequency of involuntary euthanasias involving hospice patients, is yet to be determined. However, the well-documented problem of health care fraud involving under-serving patients in hospices would likely serve as a motivating factor in encouraging family involvement in the involuntary euthanasia of the patient. Excellent hospice care is incompatible with the need for euthanasia. Hospice or palliative care is not equivalent at all to simply sedating the patient and pushing the patient into a medically-induced coma, and then into death. Real hospice care involves an increase in the quality of life for the patient and family, extends the life of the patient and allows for a natural death in its own time.

  1. Are there financial incentives for a family member to want the patient dead...perhaps an inheritance only to be distributed upon death of the patient?
  2. Is there an emotional grudge or feeling of revenge being played out, where the now weak and vulnerable patient may be retaliated against?
  3. Does the family or spouse perceive the imminent death of the patient as a solution to a problem the patient him or herself embodies?
  4. Has the patient become a burden to the spouse and/or family, and is euthanasia sought as a way of relieving the stress of caring for the patient?

These and other motivations make it even more believeable that some family members might act to medically kill the patient in their family, with or without the knowledge of the patient's physician and/or nurses. Two of the four hospice cases cited above involve family members being involved in the medical killing working in concert with hospice staff members.

It is evident from the research and from reports received by Hospice Patients Alliance, that family involvement in the involuntary euthanasia of a patient is a significant factor which must be recognized and responded to for such involuntary medical killings to be prevented in the future.

Financial Incentives to Hospitals, HMOs and the Government

Hospice care is the appropriate solution to reducing acute care treatment of dying patients. Hospice is appropriate for relieving symptoms in the terminally ill, because the patient's disease process is truly not curable and further curative treatment is futile (not effective) and will likely result in further distress to the patient.

The reality of so-called "futile care" is experienced every day in hospitals, and physicians, social workers, nurses and others may be deeply troubled by the suffering caused by the inappropriate use of modern medical technology to artificially prolong the life of a terminally ill patient with no resulting increase in quality of care, with what is often a reduction in the quality of care. Many patients do not wish to live in an artificially sustained manner, either on ventilators or even heart-lung machines. Just because medical science can do something does not make it ethical or desirable.

Financial Incentives to Euthanize Patients
With or Without Their Knowledge or Permission

For non-profit as well as for-profit hospitals, nursing homes, and hospices, patient census equals a corresponding revenue stream: increased patient numbers allows for the ability to bill for services rendered, which hopefully results in cash-flowing into the agency. This is the normal course of events and is quite appropriate. Every hospital, nursing home, or hospice requires funds to provide its services to the patients.

In a hospital, increased patient acuity results in increased patient care needs, medical treatment interventions and resulting costs. A time comes where the increased acuity of the patient does not result in a positive cash flow, but may result in an actual net loss. Perhaps, the patient's HMO or health care insurance will not pay for increased interventions. The arrival of DRGs and managed care have made it almost a given that many interventions may not be reimbursed or if reimbursed, may not be reimbursed at the rate which allows for a net profit or increased revenue stream.

Hospitals have discharged patients into other care settings, to reduce the hospital's financial burden and avoid harm to the hospital's financial well-being. Whether or not it is medically appropriate to discharge the patient is often not the determining factor. There is more than overwhelming evidence in medical literature and anecdotal accounts of patients being discharged from hospitals before they were stable enough to do so. These cases are not necessarily terminally ill patients, but rather, for example, mothers with recent caesarian section operations, patients with various surgeries, patients treated for various diseases, and other situations.

When a patient discharge is decided based upon financial considerations, rather than patient care needs, a very real danger is created which may result in harm or even death to the patient. A medically inappropriate decision to discharge may in fact be a decision resulting in the death of the patient ... a death which would not hav resulted had the patient remained in the hospital and received appropriate medical care.

Financial Incentives To Euthanize Patients
In the Hospice Setting

In hospice, so long as a patient is fairly stable, he receives the "routine home care level of care" (reimbursed at approximately $100 per patient per day) which involves a full range of periodic services on a non-intensive basis: visits by social workers (once per month or more), RN case managers (once or more per week), home health aides (once or more per week), ministers/rabbis (as desired by patient and/or family), even therapists in some situations. When the patient's condition enters into symptom crisis mode with uncontrolled symptoms which are severely distressing to the patient, the hospice is authorized to place the patient on "continuous nursing care level of care" if the patient resides at home, or on "general inpatient level of care" if the patient resides in a hospice facility or hospital wing with palliative care treatment.

Continuous nursing care level of care and the general inpatient level of care, in hospice, have specific criteria which must be met and involve a greater dedication of hospice staff services to the patient. In continuous nursing care level of care, 8 to 24 hours of nursing care must be provided and 1/2 of that must be directly provided by a licensed nurse. This continuous nursing care is provided "up to 72 hours (or three days)" at which time the patient may continue to receive such intensive continuous care or be transferred to a hospice facility or hospital palliative care wing.

With regard to general inpatient care level of care, the patient receives more intensive nursing intervention in the facility. With both continuous care and inpatient care, the hospice receives approximately $400 or $300 more per patient, per day(respectively). If full services are provided, as is appropriate during a symptom crisis, the hospice is not making huge profits but rather will tend to break even in terms of costs and revenues. Dedicated hospice managers have reported to Hospice Patients Alliance that they do not make "huge amounts of money/profit," but can with careful financial management, provide needed services to the patients and still receive the funding they need. There are some hospices and hospice organizations that have publicly asserted that funding for services is inadequate. For-profit hospices are prominent among those asserting the insufficiency of the funding provided, though nonprofits are also represented.

If a hospice patient continues in a crisis mode past the three day period envisioned in the regulations, the hospice will certainly need to justify any continued billing at the much higher continuous nursing care rate. Documentation is aimed at demonstrating continuing decline of the patient and/or continued crisis with out of control symptoms. Even with the obviously decling hospice patient, experiencing distressing out of control crisis symptoms, a hospice may perceive a need for the patient to pass on (shocking but true) for the hospice to avoid unwanted government inspection and investigation. It may be an easier solution to euthanize the patient who is declining, but too slowly for the current regulatory climate.

In other situations where the patient is actually terminal, there may be pressures perceived by the hospice to avoid having patients live beyond the six month period. Even though the US OIG and DHHS has directly stated that a hospice patient living beyond six months will not necessarily cause action to be taken against a hospice, some hospices fear such government intervention. In these cases, and where a truly terminal patient lives beyond the six months suggested period, a pressure may be created to euthanize the patient.

In the scenario where a hospice has a non-terminal patient, revenue flows as a result of billing for each and every day the patient is enrolled in the hospice. If the patient fails to die within the suggested six month period, questions may arise from fiscal intermediaries who review billings: was this patient terminal or was the patient a chronically ill patient fraudulently enrolled in the hospice? The problem of chronically ill patients being enrolled in hospice is well-documented by the US Office of Inspector General. If the hospice euthanizes the non-terminal patient, there is no immediate "red flag" allowing for detection of health care fraud in the patient billing record (emphasis on billing). So, euthanizing the patient protects the rogue hospice by destroying the evidence of the fraud: a patient living beyond the six month suggested time period.

Catch 22: Safeguards and Regulations Themselves
May Result in Unwanted Involuntary Euthanasias,
What Safeguard Can Effectively Protect the Patients?

With or without health care fraud involved, hospices may feel a pressure to euthanize a patient to avoid government scrutiny. If a hospice enrolls chronically ill patients into hospice to increase revenue, it may have patients euthanized after a certain "acceptable" period of time passes, so that a very long living patient doesn't attract the attention of federal regulators. Even if a patient is actually terminal, but is not declining fast enough and living longer than the statistical six month probability, there could also be a tendency on the part of some hospice staff or agencies to avoid federal review by euthanizing the patient. The regulations are created to prevent fraud, but may have unintentional consequences that result in increased numbers of involuntary euthanasias. Families may also be motivated to euthanize patients, for varying reasons, such as getting an inheritance or ridding themselves of what they believe is a burden: caring for the patient in the home. Nurses and/or physicians may have an agenda of euthanizing patients. For all these reasons, patients are being euthanzied involuntarily in the US.

We believe the following are important steps in preventing involuntary euthanasias:

  • Educating patients and families about the realities in health care.
  • Having patients prepare carefully written advanced medical directives, prepared with the legal advice of an attorney. Brief forms stating that a patient does not want to be resuscitated "in the event of a terminal condition" are not adequate at all. See Advance directives often are not specific enough to guide end-of-life medical decisions and Advance directives often don't influence end-of-life patient care.
  • Increased funding for hospice services so that hospices will not have adequate revenue to cover patient care service expenditures. However, it is not yet determined whether the increased funding should come from government or the private sector through charitable donations. Some argue that when government becomes involved in providing more health care, budgetary concerns will interfere with ethical medical decision-making and result in medical killings. For that reason, we encourage the creation of more non-profit hospices and greater awareness of the charitable mission of these hospices so that donations to this vital national mission are increased.
  • Proper hospice training and preparation for all physicians, nurses and other staff is essential.
  • Increased training in palliative care for medical and nursing students.
  • Increased legislative recognition allowing for the appropriate and adequate administration of analgesic pain medications including narcotics and/or sedatives (when appropriate). Such legislation would recognize well-established medical protocols for pain management and would involve protections for physicians who prescribe narcotics for the relief of pain and followed standard protocols established by the medical profession, thereby alleviating physician fears of prosecution for proper pain management interventions.
  • Prohibitions against the entry of for-profit corporations and HMOs into the hospice arena... a simple return to the nonprofit hospice model. For profit corporations which have a prevailing dedication to increased profits/dividends for stockholders have over-riding conflicts of interest in providing adequate patient care services and may routinely make decisions based upon stockholder interests rather than patients' needs.
  • Education for local district attorneys and state attorneys general, into the reality of involuntary euthanasia and what constitutes violations of human rights and unlawful medical killings.
  • Government investigations into the problem of involuntary euthanasias or medical killings in the hospice setting. We specifically urge Congressional hearings, Presidential task force involvement, and investigations by the General Accounting Office and the Agency For Healthcare Research and Quality.
  • We also urge the creation of a dedicated central involuntary euthanasia review board (CIERB) - department within either the State health departments or within the Department of Health and Human Services, Office of Inspector General, to receive and investigate reports of involuntary euthanasias in our nation. This task force would have participation by physicians, attorneys, nurses, social worker and lay person representation.
  • The central involuntary euthanasia review board (CIERB) would refer cases to the state attorney general's office or US Justice Department for further investigation and possible prosecution if justified. Physicians could be expected to oppose the creation of such as a review board, but physicians must not be given the power to medically kill patients without any supervision other than state medical boards who often do not act in such cases. Hospices, physicians and the government agencies have failed to effectively police the hospice industry. Increased federal and state intervention is necessary for the protection of U.S. citizens.

U.S. citizens (and many vulnerable throughout the world) ... patients, are dying, involuntarily, even when they are non-terminal and do not have life-threatening illness. These U.S. citizens have human, patient and legal rights not to be terminated against their will. We affirm the basic right of a U.S. citizen (and all human beings) to not have his own life prematurely ended through medical killing in a hospice setting.




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