The business of dying: as baby boomers age, for-profit entities are increasingly entering the hospice industry.

• Author: Marshall, Lisa
• Position: Industry overview

When death slowly made its entrance for 66-year-old Roger Deal, it looked nothing like his family had expected it would.

"I guess somehow we thought he would just fall asleep, and that would be it," said Carol Deal, Roger's wife of 47 years.

Instead, just days after doctors told the family there was "nothing left to be done" in Roger's 8-year battle with colon cancer, radical changes overcame the charismatic man who once vigorously tackled Colorado's toughest bike races and coached four sons through years of baseball.

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First came the memory loss and delirium, as his liver and kidneys began to shut down and the oxygen levels to his brain began to diminish. Then came the incontinence and an inability to eat or sleep. Then came the pain and agitation that frightened his loved ones as they tried to help comfort him at home.

"We were lost," said Carol, 67. "We didn't know what to do."

Enter The Denver Hospice, which admitted Roger to a calming facility with specialized end-of-life care, and promptly encircled his family with counselors who prepared them for the physical and emotional realities to come.

"They explained it beautifully to us when we got here: the process of the soul leaving the body," said Carol, seated peacefully next to her husband as he described visions of John the Baptist coming to visit him that morning. "It has helped us so much as we have watched it happen."

Roger Deal is among the roughly 1.2 million terminally ill patients who turn to hospice each year in pursuit of the most dignified death possible. Born in the 1970s as a grass-roots effort to improve the nation's somewhat abysmal end-of-life care, hospice now serves more than one-third of the nation's dying, primarily in their homes, but also in assisted living centers or inpatient care facilities like the one where Roger Deal spent his last days.

By all accounts, that number will continue to grow, as baby boomers age and demand what has come to be known as the "good death." But with its remarkable success has come a sea change for the hospice movement, as it has evolved from a volunteer, wholly philanthropic endeavor to a fiercely competitive $9 billion industry, complete with marketing consultants and quarterly shareholder reports.

In Colorado, there are now 47 hospices: 53 percent are nonprofit; 36 percent are for-profit, and the remainder are government run. On a national level, the number of for-profit hospices increased fourfold between 1994 and 2004, more than six times the rate of growth for nonprofits.

"When we look at new hospices that have opened in the last four years, 90 percent opened as for-profits," says Cordt Kassner, executive director of the Colorado Hospice Organization. "When we look at hospices that have closed over the last four years, they are 90 percent not-for-profits."

In essence, the good death has become big business. And as the trend continues, some question what that will mean for patient care.

"The biggest concern is: Will the for-profit world be providing the same high quality care that people have come to expect out of hospice?" says Dr. Jean Kutner, a palliative/hospice care expert with the University of Colorado Health Sciences Center.

The answer depends on whom you ask.

'WE DO NOT HAVE TO CURE TO HEAL'

The modern hospice movement was born in the 1960s, at a time when respirators and other life-prolonging technologies were first becoming common in hospitals, and death, like birth, was becoming increasingly sterile and medicalized.

"Back in the '50s and '60s, end-of-life care in hospitals was atrocious," Kassner says. "There was no...