Introduction

The delivery of health care services are changing.  These services are not only being provided by technically proficient professionals, but are also being provided by paraprofessionals, such as nurse's aides, mental health technicians, etc., and lay people with a special interest and/or skill in specific health care areas.  Hospice volunteers are a prime example of the shift in health care, from the utilization of professional health care personnel as the primary care-givers, to the utilization of paraprofessional and lay personnel in the care for the terminally ill.  Hospice programs have grown from a few hundred chapters, throughout the United States, in the past ten years, to over 1,700 chapters as of 1989 (Foos-Graber, 1989, p.383).
     Hospice's purpose is to provide support and care for persons with a limited life expectancy so that they can live as fully and comfortably as possible (Hospice, 1989).

An interesting references is made about Hospice programs in John Naisbitt's book, Megatrends (1984).  In determining the controlling trends in our society, Naisbitt observed that every new development of high technology is followed by a balancing development of "high touch."  Our humanism, he argues, demand this.  With the advances in medical technology-an impersonal, scientific enterprise-the birth of Hospice, a personal, nontechnological alternative form of medical care was to be expected (Outerbridge & Hersh, 1991, p.106).  In societies where death is and accepted part of life, the services of Hospice programs can provide an alternative to the institutionalization of hospitalization or nursing home care for the dying individual.  A terminally ill person can decide if he/she wants to die at home.  In a recent survey, 4 out of 5 people said they would prefer to die at home, though in practice 4 out of 5 people die in an institution (Levine, 1982, p.292).

Hospice is a coordinated program of palliative and supportive services provided in both the home and inpatient settings which provides for physical, psychological, social, and spiritual care for dying persons and their families.  Services are provided by a medically directed interdisciplinary team of professionals and volunteers.  Hospice provides support and care for persons in the last phases of incurable disease so that they can live as fully and comfortable as possible.  Hospice recognizes dying as part of the normal process of living and focuses on maintaining the quality of remaining life.  Hospice affirms life and neither hastens or postpones death (Outerbridge & Hersh, 1991,  p.105).  The volunteer program of Hospice is an essential component of the care giving team (Dubois, 1980, p.97; Buckingham, 1983, p.45).

The volunteer staffs of the numerous Hospice organizations, in the United States, consist of various lay and paraprofessional personnel.  Volunteers may serve as direct care givers, receptionists, public speakers, photographers and writers, researchers, leaders of volunteer teams for specific tasks, etc.  Volunteers do not replace paid staff, but do provide needed support and supplement the services Hospice is able to offer (Buckingham, 1983, p.25).

Discussion

The Hospice program provides comfort and support to both the terminally ill individual and his/her family and friends.  Terminal illnesses cause demoralization and turmoil in the dying person's life and relationships.  Constant misery, forced relinquishment of the activities and roles that supported the patient's self-esteem and gave his/her life significance, the threat of suffering and death - all may generate feelings of anxiety, impatience, and progressive withdrawal in those close to him/her, especially when his/her illness threatens their security as well as his/her own (Frank, p.123).  The needs of dying Americans can be summarized in four conclusions that can be used to evaluate the effectiveness of Hospice services.
 1. The needs of the dying adult.
 2. The special needs of children.
 3. The needs of the bereaved.
 4. The characteristics of the professional personnel that manage the process of death (DuBois, p.57).
The professionals and volunteers involved with the Hospice program meet these needs.  The hallmarks of a Hospice program are that:
 1. The goal of treatment is comfort rather than cure.
 2. Pain control is a priority.
 3. All symptoms are treated to enhance the patient's comfort.
 4. Care encompasses the physical, the emotional, the mental, and the spiritual.
 5. An interdisciplinary team approach is used.
 6. The unit of care is the whole family, which includes friends caring for the patient as well (Taylor, p.xiii).

The emergence of the Hospice movement has effected a change in attitude in dealing with dying and death.  Hospice provides a health care alternative that supports health care delivery by paraprofessionals and lay people.  The attitude toward a dying person has changed from "There is nothing more we can do to help," to "We need to provide the best human care possible," (Kalish, 1981, p.268).

The Hospice programs are operated following central values that are adopted and followed by most Hospice organizations.  According to G. W. Davidson (1985), there are 5 central values of Hospice:
 1. Dying is a human experience.
 2. Dying persons are ends in themselves.
 3. Dying persons are self-determining.
 4. Dependence and need are not demeaning.
 5. The basic unit of care is the community (p.164).

The direct care paraprofessional and lay volunteers of Hospice provide the terminally ill person and his/her family and friends with on going support that allows the participants, in the dying process, to safely ventilate their feelings, without guilt.  Volunteers support the family and friends of the dying individual by allowing them to be able to take some time to continue their normal daily activities, such as going to the store, taking others to scheduled  appointments, while the volunteer stays with the dying person.  A volunteer may also help the family and friends of the dying person by taking the patient to medical appointments, when the family and friends are not available or have other responsibilities.  Hospice volunteers attempt to assist the individual, family and friends maintain some elements of a "normal" life.  Several studies have demonstrated the effectiveness and benefits to the dying person, his/her family, and friends.  Hospice patients were more mobile and related their physical pain as less severe and not due to drug-caused confusion.  Hospice patients were less anxious and depressed (Kalish, 1981, p.269).

Hospice volunteers also serve as spokespersons for Hospice programs.  They are available to speak to groups and organizations that are interested in knowing more about the philosophies and services being provided by Hospice.  Hospice's relationship to the community can further public education about the terminally ill as well as uncover the often suppressed issue of death (Buckingham, 1983, p.52).  Ongoing public education about the doings of a local Hospice increases the community awareness.  Hospice can contribute to public awareness and acceptance of death by continuing to be a community within a community (Buckingham, 1983, p.70).  The public awareness programs, provided by the Hospice volunteers, can impact the on-going funding of the Hospice programs.  Hospice funding comes from a variety of sources:  individuals and foundations, third-party payors (private carriers, Medicare, Medicaid, state and local government), and donations from such groups as the United Way (Buckingham, 1983, p.62).
 The direct care paraprofessional and lay volunteers play an important role in the health care delivery of services to the terminally ill without monetary compensation.  The volunteers receive basic and continuing education to develop health care skills for working with the terminally ill.  In order for the direct care paraprofessional and lay volunteers to be an integral, effective part of the interdisciplinary health care team, they must be able to have input into the individual health care plans of the Hospice patients.

While everyone must eventually face his/her own death, the experience of dying, shared by a patient and his/her family and friends, has not traditionally been incorporated as a part of the healing process.  Rather, death is perceived as a failure of healing, and therefore is rarely shared or discussed (Jaffe, 1980, p.49).  Healing is more than physical, psychological, or emotional.  Healing is also spiritual.  The healing of the spirit allows a depth of understanding that is beyond normal consciousness (Levine, 1982).  It is a paradox that as death becomes personalized, a life force becomes energized.  In the very jaws of this danger is the opportunity, the chance for no less than a second christening (Sheehy, 1977, p.356).  The time that a terminally ill person has left in this life should be used to grow spiritually and in self, in order to prepare to leave this life (Foos-Graber, 1989; Levine, 1982).

The professionals, in Hospice programs, focus the majority of their attention to the physical and psychological needs of the dying individual.  The Hospice chaplains and direct care volunteers focus on those needs along with some of the spiritual needs of the dying person by being good listeners and available to the individual's needs.  Hospice professionals tend to focus the person consistently on "being in the body," while administering palliative care.  The sense of "being in the body" is the very thing which the dying person is losing.  With so much attention focused on the physical aspect of the dying person's life, there can be a lot of loneliness in Hospice, especially for people who have strong spiritual interests.  In many Hospices the predominant goal is the alleviation of distress, the palliative care of the patient.  There is little encouragement to cut through identification with the body as being who we really are or the mind as being the whole reality.  Hospices can have a tendency to overlook dying as a means of spiritual awakening (Levine, 1982, p.169).  The dying person needs to deal with the real issues - the spiritual issues, not the waning body and personality issues (Foos-Graber, 1989, p.304).  In certain societies, the victim's expectation of death may be powerfully reinforced by attitudes of his/her group (Frank, p.128).  The direct care volunteer staffs of Hospice offer the dying individual the opportunity to express his/her thoughts, concerns, and beliefs without being judged.  The role of the direct care volunteers are to be attentive and to be good listeners.  The volunteers listens to and respect the person's point of view and/or spiritual beliefs but do not express his/her point of view and/or beliefs.  The paraprofessional and lay Hospice workers allow the dying person the opportunity to explore his/her spiritual awakening without judgement.  There is often less resistance to the unknown when one is surrounded by the familiar and can work day by day to open to his/her predicament, to discover the strength and spaciousness that lies within, that allow a deeper participation in the next unfolding (Levine, 1982, p.292).

Summary

Each society defines its own system of healing, which includes both professional and lay networks and interventions.  Many health problems can best be dealt with not by responding to the individual needs, but intervening on a social level (Jaffe, 1986, p.39).  The professionals, paraprofessionals, and lay people involved in Hospice programs provide social intervention into the dying process by assisting the dying individual and his/her family and friends and by educating the public to the realities of dying and death.

Through the services of Hospice, the dying individual, his/her family and friends can grow as a result of experiencing another's death.  Growth is measured by the gentleness and awareness with which we once again pick ourselves up, the lightness which with we dust ourselves off, the openness with which we continue and take the next unknown step, beyond the edge, beyond our holding, into the remarkable mystery of being.  Going beyond the mind, we go beyond death.  In the heart lies, the deathless (Levine, 1984, p.xiv).

Hospice programs are expanding and the need for additional paraprofessional and lay volunteers are increasing.  The 1970s were a decade when Hospices began working with people in their homes.  The 1980s was the period when Hospices solidified its contracts with hospitals and obtained legislative ability to receive health insurance reimbursement for their patients.  The 1990s will increase the home and hospital work with additional work within nursing homes (Outerbridge & Hersh, 1991, p.113).

Hospice care is not appropriate for everyone: some deaths do not permit Hospice care; some health conditions require equipment or treatment not available in Hospices; some persons will find the program unsuited to their personal needs (Kalish, 1981, p.269).  However, for the terminally ill people and their family and friends that want to maximize the experience of death, Hospice programs provide the health care services that can meet this need.  To bring one home to die is like accompanying one on his last pilgrimage.  There is no experience more intimate than to be with someone during the process of death (Levine, 1982, p.203).

The power and treatment of the terminally ill patient are in the hands of professional, paraprofessional, and lay people in a Hospice program.  The direct care paraprofessionals and lay volunteers provide supportive health care services to the dying and their family and friends.  They work to enhance the care and support of patients, families, and friends in a "high tech", "high touch" society (Naisbitt, 1984).