Life Force

Dr. Ira Byock begins his morning rounds at Dartmouth-Hitchcock Medical Center by delivering newspapers. With 15 copies of the Valley News tucked under his arm, his first stop is the chemotherapy clinic. Cancer patients lie on recliners while receiving their infusions, their expressions less of worry than of boredom. For each patient he holds up the front page. "Would you like a paper?" Most people brighten at once and say yes. So do patients in the radiation unit, and people in the cancer center's main waiting room. Even though Byock is the director of palliative care at the Lebanon, New Hampshire, hospital, he relishes this distinctly nonmedical task. "It costs nothing, and it acknowledges all the queues you're sitting in when you have cancer," he explains later.

That personal touch defines the 55-year-old Byock and his work, which is transforming the way people with terminal illnesses are treated in the state - and which he hopes will influence the rest of the nation as well. Since Dartmouth-Hitchcock recruited him in 2003, a growing number of the region's hospitals, doctors, and health-policy analysts are embracing the medical discipline of palliative care, an inpatient application of hospice principles. Healthcare consumer advocates say Byock is helping change how people die by changing how they live.

"Nobody ever said to me there was no need to experience all this pain," says Ron, 65, a southern New Hampshire resident whose leukemia treatment did not succeed. Years ago, he says, when he had hip surgery, "I was writhing in pain, begging this nurse for more medicine. She just said no." His experience with palliative care could not be more different - from pain control to the care taken in reporting test results to emotional support for his wife. "This time they're doing it right, taking it from every angle. Ira's part is totally new to me."

"Ira's part" - palliative care - concentrates on comfort rather than cure. If a person dying of bone cancer is in pain, for example, palliative care treats the discomfort and leaves the cancer to other specialists. Patients actively participate in decision-making, and they and their families often receive counseling, spiritual support, and bereavement services. Since Byock arrived, Dartmouth-Hitchcock and New Hampshire have seen dramatic changes in palliative care.

An estimated 3,200 patients received such care last year at the hospital, up from 1,100 in 2003 in a state with about 9,700 annual deaths. In addition to overseeing patient care, Byock has helped build a corps of volunteers who visit people facing long hospital stays. He has also recruited a new chaplain for the hospital experienced in end-of-life care, and has taken his advocacy on the road, speaking at churches and teaching palliative care to hospitals and nursing homes. Although Massachusetts and other New England states have isolated palliative care programs, Dartmouth-Hitchcock's dominant size in an otherwise rural system enables a more connected network of care.

Byock's most ambitious project is just beginning, though. In October, he announced plans to make end-of-life care a central issue when presidential candidates canvass the Granite State this year. The initiative will begin with community forums and later involve policy papers, as well as questionnaires for candidates. Only 25 percent of United States hospitals have palliative care programs. The obstacles include limited insurance coverage and Medicare reimbursement to physicians, insufficient training of medical students in this area, and a lack of professional and financial incentives for doctors to specialize in this care.

Byock is no neophyte in his cause. In the late 1970s and early '80s, when hospice was still a new idea in this country, he helped establish a hospice program in California and directed another in Montana. Later, Byock received a $15 million grant from the Robert Wood Johnson Foundation to develop models for care the whole nation could use. He also wrote two books on the subject, one of which chronicled his father's 18-month ordeal with pancreatic cancer. In 2003, Dartmouth-Hitchcock came calling.

"No one in the country understands the philosophy and practice of palliative care better than Ira Byock," says Frank McDougall, Dartmouth-Hitchcock's vice president of government relations. In recruiting terms, Byock was also something of a twofer. His wife, Yvonne Corbeil, is internationally known for her work in end-of-life- care administration. Now she's executive director of the New Hampshire Hospice and Palliative Care Organization, of which Dartmouth-Hitchcock is a member.

Byock's work requires a tenacity in challenging conventions. When his turn came to provide a speaker for grand rounds, a medical staff event that usually features a major researcher or clinical authority, he invited US poet laureate Donald Hall to read poems about love and death. "Helping people deal with mortality is somewhat antithetical to the culture of medicine," Byock says.

He adds that the core of palliative care, ultimately, is not law or policy, but the ongoing interaction with patients. When Byock enters Ron's room, he sees the visitor's chair against the far wall but instead sits in Ron's wheelchair and rolls it close to the bed. He begins: "What can I do for you today?" Ron teases Byock relentlessly - for being a Democrat, for reading poetry. Byock teases back. Later, Byock explains how his goals differ from those of ordinary medicine. "Dying is more than a series of medical problems to be solved," he says.

So, each morning, Byock's team reviews not only the medical but also the emotional status of the patients. The group will look at test results and discuss who has special needs that day. As soon as the meeting breaks, Byock gathers his newspapers on a desk. He watches the team filing quietly out of the room, then grins and opens his arms wide. "Hey, spread some joy, will you?"

Stephen P. Kiernan is the author of Last Rights: Rescuing the End of Life From the Medical System. He lives in Vermont. Send e-mails to magazine@globe.com.