Passing On
Cathy and Linda were the same age, grew up in the same place, and could have been girlhood chums. Instead, they met when Linda was terminally ill and Cathy, a hospice nurse, was assigned to ease her final days.
On November 18, 1980, Linda Mihlan, a 29-year-old mother and housewife in Mesquite, died of cancer of the cervix. She died in her living room, sitting next to her husband, Chuck.
At the moment of Linda’s death, Chuck was talking on the phone to Cathy Little, who is a hospice nurse. Her job is a fairly new one in the world of health care. She looks after people who are dying, who are beyond medical help. Cathy has chosen to spend her life making other people’s deaths slightly more bearable—an ever-larger calling in America, one that sometimes attracts mystics and kooks and one that utterly fails to satisfy a constant demand on modern medicine—that it offer hope of recovery. And yet, for Linda and Chuck Mihlan, it undeniably eased the pain.
Linda’s mother was already dying of lung cancer when Chuck and Linda began dating. In Chuck, Linda’s mother saw a chance of security for her daughter: he had a kind voice, temperate habits, and the prospect of a good job. He was the sort of man, she believed, who would make a good father to the three children from Linda’s first marriage.
Linda’s life had always been a cause for worry. Reared in lower-middle-class poverty in the Garland-Mesquite-Balch Springs area, she had quit school after the ninth grade and married young. She worked as a waitress and bore three boys to her first husband, a hard-drinking, fast-driving man. Now the children were a burden to support. When Chuck came into Linda’s life, Linda’s mother asked them from her deathbed to marry before she passed away.
Chuck did not want to marry until he had known Linda for a full year, but he didn’t want to frustrate a dying woman’s wish, either. In November 1975, five months after he met Linda and only weeks before her mother died, Chuck and Linda were wed at her mother’s home in Mesquite. They moved into a Dallas apartment. Linda stayed home with the kids, and Chuck took himself off every day to his new job as a hydraulics mechanic at an oil field supply plant.
Linda’s health had never been good, and it did not improve after her marriage. Within three years she had her appendix removed, was diagnosed as diabetic, and had a benign tumor removed from her breast. In order to understand these and many other, minor ailments, Linda sometimes paged through a set of medical encyclopedias inherited from her mother, the sort of books sold in grocery stores. But not until the fall of 1979, four years after her mother’s death, could Linda read the chapters on cancer.
For more than a year Linda had been bothered by a vaginal discharge, especially on nights when she and Chuck made love. On two brief pages of The New Illustrated Medical Encyclopedia for Home Use she found such a discharge described as symptomatic of cervical cancer. Once she had diagnosed herself, Linda lost no time. She asked Chuck to accompany her to the doctor’s office, and while she was being examined, he sat in the waiting room, ill-humored at having given up a day’s work to placate his wife’s insatiable obsession with illnesses. Half an hour later, when Chuck was called in, Linda was crying. “Your wife has cancer of the cervix, but she has a good chance of surviving,” the physician told Chuck. But Chuck was distressed. After all, cancer is cancer, isn’t it?
Tumors of the female organs, which thirty years ago accounted for 1 in 5 cancer deaths, account for only 1 in 10 today. In Texas deaths due to uterine cancer have declined from about 750 a year in 1950 to about 580 today, and across the nation, some 78 per cent of women stricken with cancer of the cervix live for five years or more if diagnosis is early. In other words, a diagnosis of cervical cancer no longer means probable death, even in cases like Linda’s where diagnosis comes late. Her doctor was within the statistical bounds of reason when he counseled hope and speed.
The doctor had scheduled further tests for Linda at Pleasant Grove Hospital the following Monday. After the tests Linda asked Chuck to see a lawyer about adopting the children, so that they would be his if she should die. She then called the children together so Chuck could tell them what was wrong. “Linda has cancer,” Chuck said. “Do any of you guys know what that means?”
“Yes,” blurted six-year-old Jimmy, “it means that Mommy is going to die!” Despite assurances that death was neither imminent nor certain, the boys wept. That Christmas Chuck and Linda gave the children everything they asked for. Under the tree the boys found a stereo set, racing cars, and a dozen lesser goodies.
But Linda’s condition did not improve. At Easter she was in the Baylor University Medical Center hospital for a hysterectomy, which was followed by a brief and futile regimen of chemotherapy. By June her weight loss was noticeable, her strength was fading, and she was in pain. Unable to manage her responsibilities, she agreed to place the boys in the Buckner Baptist Children’s Home in Dallas. They did not want to leave her, but Linda was in the hospital as much as she was home now, Chuck had an obligation to work, and there was no one to care for them.
Money was scarcer than it had ever been. Chuck had medical insurance for his family through his employer, but it paid an annual maximum of $10,000 per beneficiary. That amount was exhausted by the time summer began, as were the couple’s savings. Because Linda could no longer drive, Chuck had to miss work in order to accompany her to hospitals and clinics; because there was no money, he had to go into debt to keep her out of pain. Even with the kids at Buckner, Chuck had more work at home than one man could handle.
Sympathetic hospital personnel advised Chuck to call upon the Home Hospice Program. The Dallas Visiting Nurse Association (VNA) hospice, established in 1978, is one of the nation’s largest home care programs for terminally ill patients. At any given time VNA Home Hospice nurses, aides, and social workers are providing advice, treatment, and household help for one hundred terminal patients, most of them cancer victims.
The term “hospice,” which denotes a place of shelter, has for three decades been used in Britain as a name for hospital wards devoted to the care of the terminally ill. The first modern hospice, St. Christopher’s in London, opened in 1948 and set a standard for similar institutions. Hospices, wherever they are, provide staple medical services like oxygen administration and intravenous feeding, but because treatment in terminal cases is largely palliative, they specialize in pain control. Programs built on the British model also offer patients and their families a variety of counseling services, including advice on wills, funerals, and pensions. They deliver services to the patient through teams composed of doctors, nurses, social workers, and volunteers, many of whom are the survivors of former hospice patients. Hospices bring experienced personnel to the assistance of dying patients, but as Chuck Mihlan would learn, they cannot resolve all, or even the most painful, problems associated with death. In hospice theory, and in ordinary practice, the team members function as aides to the patient’s family—upon whom final responsibility rests.
Last July—about the time Linda came into the Home Hospice Program—it and 25 similar projects across the nation were released from the Medicare system’s restrictions on the type and number of visits that would be reimbursed. That federal endowment, though it did not directly affect Linda, did lessen the hospice’s dependence on funds donated by survivors of former patients.
The hospice did not charge Linda and Chuck for hospice visits to their home. The VNA also used privately donated funds to hire household help for them for four hours a day. It dispatched David Overton, a bearded 27-year-old social worker, to assist the couple in facing the traumas of impending death and to help in maintaining contact with the three children in Buckner. The VNA hospice also assigned 26-year-old Cathy Little to visit Linda’s bedside. Cathy had been a hospice nurse for less than a week when she drew the assignment. It proved to be a good test of her preparedness for the new job.
In many ways Cathy fit the profile of nurses whom hospice work attracts. She had not been a traditional nursing school student. Throughout her formal education she had enjoyed literature more than math or science, and in her personal and political views she was trendy and liberal, not staid or traditional. She was convinced that the hospital setting discouraged warmth and closeness. But Cathy pursued nursing anyway, because the work itself appealed to her. Times were changing, women’s liberation was making inroads everywhere, nursing was winning a new dignity—and a new clout—and in that ambience Cathy hoped she could find a place for herself.
For three years after graduation Cathy shifted from job to job, looking for professional contentment. She worked for an oncology, or tumor, hospital; on a cardiac intensive care unit; and on a neurosurgical intensive care unit, all in the Dallas area. She was not favorably impressed. Hospitals were hurried, businesslike institutions, she thought—and working in them was like working in a factory or store. Her patients on the intensive care unit reminded her of greenhouse plants: silent, unmoving, and artificially maintained. Cathy wanted to get away from the chilly atmosphere of organized medicine.
Her superiors in the hospice program hired her because she had technical expertise, because she was experienced with terminal patients, and because she was reasonably well insulated against a common hazard of hospice work, career burnout: her boyfriend of three years, she said in a job interview, would know how to comfort her when the strain of working with dying people gave her doubts about her job. Though it meant a pay cut of $150 a month, Cathy was delighted to be hired by the hospice. No longer would she have to work under a regime of medical spit and polish. Now she would be a member of an irregular, or guerrilla, corps.
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