From commentator Mark in the thread below comes a link to this incredibly disturbing story of death in hospice.
The story is utterly believable: The kindly relative who signs the order to move his uncle into hospice after being confronted with the uncle's advance directive. The relative's eventual realization that "including nutrition and hydration" on the advance directive is taken to mean all nutrition and hydration, even when the patient can eat by mouth. The unnecessary medication with morphine of patients who are not in pain--automatically, just because they are in hospice. And eventually, the tyrannical nurses and doctors who stop the Filipino orderlies from "sneaking" food to patients who must die. The final scene, where the relative listens to a nurse rant about the importance of advance directives while watching over her shoulder as an orderly, seeing the nurse not watching, sneaks into another room to feed a patient, caps it off. The author says that at that moment he chose his side.
I find notable in the story the fact that everyone involved assumes that somehow these patients, including the uncle, had chosen to die in this way by signing advance directives. No distinction is even attempted between artificial nutrition and hydration and feeding by mouth. That distinction didn't last long! And here we were all told that the reason people were starved and dehydrated to death was because "tubes" are "treatment." Welcome to the brave new world. These are patients who can eat by mouth, but the assumption is that they must be starved and dehydrated to death anyway. Even when the uncle wakes for a moment and says his first and nearly only two words, "Help me!" the nurse's instant response is to give more morphine, and that's all. (The uncle says, "No, no," the last words he gets a chance to speak, as the nurse gives the morphine.)
We should not respond to such stories with automatic expressions of faith in hospice. I don't know how widespread these practices are. In this hospice, what it amounted to was that when the doctors and nurses got iron control over the orderlies, killing the patients (by dehydration and morphine) was universal. The orderlies represent the concept many people have of hospice--of natural death at its own pace. The doctors and nurses represented a more powerful technocratic reality. At how many places is this true? I don't know. At how many places is it worse, without even the orderlies sneaking applesauce to the patients? I don't now.
And if what was done here was illegal, I can only say that no one knew that it was. Indeed, the magic of the advance directives was taken to make this sort of death legally at least permitted, if not mandatory. It was the orderlies who were perceived, by everyone involved, as the rule-breakers. There was no faintest question of anyone's prosecuting anyone; indeed, I believe no prosecutor would ever take up such a legal tar-baby of a case. The doctors have the power to enforce n.p.o. orders if they please, even for patients perfectly capable of swallowing, and who is to stop them or tell them they are killing their patients? They will claim that food by mouth is inappropriate in their medical judgement, and they will wave an advance directive at you, even if it is obvious that the patient who signed the directive didn't realize that this was what he would be taken to be agreeing to.
If you have a relative who wants to die in hospice, if you might someday have such a relative, or if someone will someday suggest it to you, you need to read this story and do all that you can to make sure that this doesn't happen to you or to someone you love. Speaking for myself, this has made me reluctant ever to agree to enter hospice anywhere. The stakes are simply too high.