With its mix of spiritual and physical comfort for terminally sick people and their families, hospice care has quietly become key to the way many people die in North Carolina.

The amount of hospice care provided has doubled during the past five years -- more than three of 10 dying state residents receive hospice services in some form.

The amount of hospice care provided has doubled during the past five years -- more than three of 10 dying state residents receive hospice services in some form.

Nearly 36,000 North Carolina patients went into hospice care last year for an average of 68 days per person, an increase of about 20 percent per person over 2002.

Hospice, which offers comfort and care in the final months or days of a terminally ill patient's life, has been embraced throughout the nation. The bill for Medicare-financed hospice care has been growing by roughly $1 billion annually and is likely to reach $11 billion next year, the National Hospice and Palliative Care Organization says.

For James Earl Cobb Sr., 80, of Henderson, hospice care has helped his mind and body after years of declining health. A former Pine State milk delivery man, Cobb faces a host of health problems with the aid of family, faith, humor and the nonprofit Hospice of Wake County.

"I stay mostly positive," Cobb said in his room at Falls River Village, an assisted living center in North Raleigh. "I don't have the gloomy days."

Cobb, who has terminal heart disease, started receiving Medicare-funded benefits in April, the month he celebrated his 25th anniversary with his second wife Willie Mae, 78. Through hospice, Cobb gets medical care for ailments not related to his terminal condition, necessary equipment, visits from clergy, social workers, nurses and nursing assistants. Family members get support, too.

"We've been told any time we need anything to call the number on the telephone," said Willie Mae Cobb.

James Cobb's case represents a national trend in which hospice care has expanded from its core business tending cancer patients. Now, care organizations treat patients who have a range of terminal diseases.

"Hospice has become more available," said Judy Brunger of the Carolinas Center for Hospice and End of Life Care, a trade group for nonprofit and for-profit services.

"It has begun to take patients and families who have a wide variety of illnesses and not just cancer, which I think is very startling to folks."

Familiar issues

Along with the growth in hospice use, however, have come issues common to modern health care: the lack of state and federal resources to keep a close eye on providers, and a blurring of lines between the original volunteer-driven model and for-profit companies that may be part of publicly traded corporations.

"Our assessment of the field is that nonprofit programs represent just 67 percent of providers," said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization.

"For-profits are about 27 percent, and the rest are government-related, like the VA programs. The growth in providers has been in the for-profit providers."

Once a mostly charitable enterprise run by faith organizations using volunteers, hospice now faces time and financial pressures familiar to other health care providers.

"I'm not going to make the statement that the concept of for-profit hospice is inherently bad," said Cooper Linton, vice president for marketing at the nonprofit Hospice of Wake County.

"The greatest distinction is that a for-profit organization's goal is to maximize profits for shareholders."

Representatives of Hospice of Wake County say people are often confused by the wave of new hospice options and associate a favorable public image of hospice with any company that has "hospice" in its name -- whether that image is earned or not.

For-profit hospices provided a "significantly narrower range of services" than nonprofit hospices, according to a study published in 2004 by Yale University public health professor Elizabeth Bradley and other researchers.

Bradley said in an interview, however, that additional studies will have to be completed before a more reliable verdict is reached on whether nonprofit or for-profit providers do a better job.

Companies tend to make more money when patients remain in hospice care longer, Bradley said, but longer stays are better for the patients and their families, too.

"That's very consistent with the profit motive in that it's a flat rate per day," she said. "It's also a very good thing for patients."

Care, compassion

Although the average stay is much longer, more than a quarter of hospice patients in North Carolina die within seven days of entering care, said Brunger, the director of hospice and end of life care at the Carolinas Center. That means they don't get the full benefit of the extra help and counseling hospice can provide.

For Helen Blackley of Cary, the extra time with hospice was a benefit to her and her husband, Harold, who died of ALS in March at age 82.

He had been at home, in the care of Hospice of Wake County, since November.

"I have never met such caring and compassionate people," Helen Blackley said.

Peggy Smith, program director at the Alzheimer's Association, Eastern North Carolina chapter, touts the benefits of hospice care to clients of her nonprofit advocacy group.

She relies in part on her hospice experience with her father, Glenn Smith, who died four years ago. Glenn Smith suffered from dementia, took several falls and could no longer stay in an adult care home without additional help.

"Based on what my dad wanted, he didn't want a lot of extreme measures," Peggy Smith said. "Our goal was to keep him comfortable."

TLC Hospice, a for-profit service, provided Glenn Smith with help that included a 24-hour nurse, a certified nursing assistant and spiritual counseling. Medicare paid for his care.

When he died, the hospice made arrangements to remove his body from the assisted living center quietly, without the clamor of sirens, emergency workers or ambulances.

"It just was an added support that people need to realize is there," Peggy Smith said.