Americans are going home to die, with hospice care to ease the burden on family. It's a reach for a dignified acceptance of the end.

MARYANNE LOHREY DROVE UP Frankford Avenue in her 14-year-old Ford Granada, windows down, lost in thought. Everywhere she went now, she saw the houses of the dead -- that house and that house and that house.

Each house and street and neighborhood conjured up a story, each one different, but also the same, the story of a death, an ending.

James Luckey, a pastor and hospice counselor, prays with Steven Jacobs, dying of a rare cancer. With him in his last days were Linda (left); a sister, Olivia (right); and his daughter, Gretchen.

Mostly, those were not painful recollections, but joyful ones, because this woman who made great lemon bars and drove an un-air-conditioned clunker had helped hundreds of people die. She was sure she had supported the families and helped the patients accept death and prepare for it, and, in the best cases, die well.

Lohrey is a social worker for the hospice program of Pennsylvania Hospital. In May this year, she was on her way to Kensington and a new patient, Steven Jacobs. All she knew was that he was 40 years old, had a family, and was dying from a nasal cancer that had spread to his lungs and liver.

She followed the directions, finally pulling onto a narrow, one-block street of cramped rowhouses. Crack dealers worked each end.

She parked in the middle of the block and walked up to the front steps wondering: How could she and her colleagues help this man die?

She knocked on the door.

HOSPICE WILL HELP nearly 400,000 Americans die this year - almost one out of every six deaths.

There are 2,700 hospice organizations nationally, nearly 50 in the Philadelphia area. Medicare spent nothing on hospice until 1982. Last year, it spent $2 billion.

This growth in hospice care is a reaction to the way many Americans have died in the last 30 years: in pain and feeling neglected by doctors; often in hospitals, attached to machines, suspended in a modern medical purgatory.

"We have created on some level this illusion that we can keep people alive," said John J. Mahoney, president of the National Hospice Organization in Washington. "In some respects, we can keep them alive. But what we've really done is just kept alive their suffering."

Hospice is a push forward, but into the past, an attempt to let people die the old-fashioned way - at home, surrounded by the things and the people they love. Hospice provides medications, medical equipment, nursing care, counseling, pastoral care, and even help with routine responsibilities - from cooking to laundry.

Steven Jacobs clasps hands with Linda Hendricks, his companion of many years. At the end, he made peace with regret at not having married her.

Growing numbers of Americans are choosing hospice, Mahoney said, because they want a humane death, a good death, a death on their own terms.

WHEN MARYANNE KNOCKED, Steven Jacobs' daughter, Gretchen Hendricks, answered the door. She was 19, just days away from delivering her second child. She had no idea who Maryanne was or what she was doing there. Maryanne asked to speak with Gretchen's mother and stepped inside.

The living room was dark and cool. Baby pictures hung on the walls, along with a portrait of the Rev. Dr. Martin Luther King Jr.and the words "I Have a Dream." A cat, Books, stretched out on the wooden floor.

Maryanne climbed the stairs to Steven's bedroom and found an emaciated man lying in a bed. Once 220 pounds, Steven now weighed 120. His head was shaved. His voice was slow, a little slurred, weak.

"I know all about you," Steven said.

Steven Jacobs had worked hard all his life, for the last 10 years monitoring alarm systems for PNC Bank branches. He graduated from Bartram High and served six years in the Marines. He believed in God and wondered what he had done - or not done - to deserve this fate.

In the bedroom with Steven were Linda Hendricks, whom Steven had dated since he was 15, and their son, Steven Hendricks, 22. Young Steven lived at home and worked as a certified nurse's aide in a nursing home. With them were two of Maryanne's colleagues who had arrived earlier - nurses John Sapovits and Nancy Juergens.

Maryanne invited Gretchen to join them for this initial meeting.

"No!" Steven Jacobs insisted, waving Gretchen away. She was confused and hurt by the rejection, and already Maryanne could see she had work to do.

After Gretchen left, Steven explained that he hadn't told her that he was dying.

With family members poised in grief, hospice nurse Nancy Juergens makes funeral arrangements after Steven Jacobs' death.

"I didn't want to tell her because she is pregnant," he said. "She's not ready to know.... Ain't nothing heavier than this."

Maryanne and the others described the services that hospice would provide - social workers, nurses, pastoral counseling, even someone to cook and clean, if needed.

Steven signed a do-not-resuscitate order. Hospice requires that the patient know that death is imminent and not fight it.

As Steven put pen to paper, Linda collapsed in tears. "You may know it up here," Steven said, pointing to his head, "but signing your name to a form, facing it, that's a whole other thing."

STEVEN JACOBS DIDN'T WANT to die. He saw himself as a provider and a protector, a man with many responsibilities still unmet. And he loved life too much to leave it so young.

Four years ago, Steven got a runny nose. His family doctor gave him a prescription, but the runny nose didn't go away. A few months later, Steven's vision grew blurry.

Linda urged him to go to Wills Eye Hospital. Soon he was getting X-rays and MRIs and talking to an oncologist, David Mintzer.

Steven had a rare, hard-to-diagnose tumor, right behind his nose. When Mintzer looked at Steven's MRI and chest X-rays, he realized the cancer had already spread and would probably kill him.

Chemotherapy worked for a year, and then the cancer became resistant. They continued to try new chemotherapies, and also to give radiation to relieve pain and control the tumor's growth. The tumor was growing through his palate.

Last winter, Mintzer faced the hardest decision for a cancer doctor: deciding when to stop treatment.

"On one hand, you're the doctor, and you want to provide hope," he said. "On the other hand, you can inflict a great amount of harm. There's a great potential to cause even more pain with pointless treatments."

Mintzer explained to Steven and Linda that he thought more treatments had slim or no chance of helping, but if they wanted to try, he would.

Linda Hendricks thanks James Luckey, a pastor, for his eulogy at Steven Jacobs' funeral. Luckey counseled Jacobs, who told him, "You take the place of my grandma and my ma. You're the shoulder I lean on."

They wanted to keep trying. It wasn't until several months later, in May, that they decided to stop.

Mintzer found more lumps on Steven's chest and side. Chemo wasn't helping. He asked Steven what he wanted to do.

"I don't want any more treatment, since it's not helping," Steven said. "I just want to go home and rest until the time comes."

Steven hadn't heard of hospice. After Mintzer explained it, he agreed to the care.

Afterward, the couple and their son drove to a drug store, and Linda went inside for a prescription.

Steven held up three fingers.

"What's that mean?" asked the son.

"That's how much longer I have to live - three months."

Young Steven started to cry.

"I'm sorry," comforted the father. "I'm sorry."

"You put up a good fight, and you have nothing to be sorry for," said the son.

"I'm proud of you," said the father.

STEVEN TOLD MARYANNE all that in her first few visits. She quickly realized she must confront two important issues.

One, she had to deal with the resentment Steven had for his family doctor, who had treated him for a runny nose. The doctor had not spoken to him since that day, even though Steven, an HMO member, had to get a referral from him for every cancer treatment.

"He didn't even say I'm sorry," Steven wept one afternoon, convinced that an earlier diagnosis of the tumor might have made a difference.

Steven Jacobs is comforted at his Kensington home. When it was cerain he would not recover from a rare cancer, Mr. Jacobs told his doctor, "I just want to go home and rest until the time comes."

There was no way for Maryanne to know whether that was true. Nor did it really matter now. What mattered was that Steven talk about his feelings and deal with them, and that Maryanne listen.

"I appreciate your honesty and sincerity," Steven said to Maryanne one afternoon, after pouring all this out. "Just be honest with me. That's what people in my situation need."

Maryanne also knew she had to persuade Steven to talk to Gretchen.

"It's not just telling her - it's helping her," Maryanne told him. "We really don't know how much time you have."

Steven told Gretchen the truth in early June, just a few days after Gretchen's son, Donald, was born. Gretchen was stunned.

A few days later, Maryanne brought the two together for a long talk. Steven was in bed, and Gretchen sat on the edge.

Steven told his daughter he was worried about her. She had no direction in her life, no goals. He felt guilty that he wouldn't be around to guide her, to help her raise her expectations.

Gretchen said she wished her father had told her sooner that he was dying. She would have spent more time with him. She didn't want to be a disappointment.

Gretchen promised she would get a driver's license and return for her GED at Temple in the fall.

"I want you to seal this with a kiss," Steven said.

Gretchen leaned over and kissed her dad.

THE NURSES PLACED A HOSPITAL BED in the living room, and Steven would be at the center of life in this house until his death. His seven siblings would visit day and night. Linda rarely left his side. When his 18-month-old granddaughter woke up from a nap on the couch, she'd toddle over and plant a big kiss on Steven.

Steven bonded almost instantly with nurse John Sapovits, who came every other day. John asked the most personal questions, but he never embarrassed Steven. The afternoon of Tuesday, June 18, was typical.

"How you feeling today?" John asked.

"OK."

"You look good. How's your pain, Steve?"

"Good."

"On a scale of one to ten?"

"Four to five."

"Move bowels today?"

"No."

"When did you go last?"

"Saturday. Sunday."

John turned to Linda. "How many suppositories do you have left?"

Linda Hendricks allows the new puppy Steven's son had gotten him in for a visit. Linda Hendricks allows the new puppy Steven's son had gotten him in for a visit.

Linda checked the refrigerator.

"Eight."

"Great," said John. "If he doesn't go by tomorrow afternoon, give him one of those."

He turned to Steven.

"We don't want you getting clogged up."

"Back atcha," said Steven.

Everyone laughed.

The conversation moved on. Steven began talking about the pain of his radiation treatments, and the nurse disclosed that he, too, had been through radiation for a cancer in his mouth and throat.

"It was the most frightening thing," said Steven. "I fear nothing, but when you're getting treated and you can't feel it, and you can't see it, but then you go home, and it's, `Oh, my God, what has happened to me?' They burned my taste buds right off my tongue. The side effects are terrible."

"They are," agreed John. "They're wicked."

"They should tell people more," said Steven. "I had no idea I would lose all this weight. I used to be 220. Now look at me."

"I was just like you," said John. "I was 220, and I lost 50 pounds in radiation." John grabbed his ample spare tire. "You can see, I've gained it all back and more."

"I wish I could borrow some."

"I wish I could loan you some."

They laughed.

Steven made a sexual reference.

"I used to be like a Rock of Gibraltar," he said. "Now I can't get a flare."

"That's the worst," said John.

"That's from radiation," said Steven. "That's the worst thing a man wants to lose."

"You're right," said John. "It is."

"I understand they do what they had to do," said Steven. "But they should explain things."

"You're right," said John. "They really should."

ON THE WEEKEND OF JUNE 22 and 23, Steven had four seizures. Hospice workers went to his house six times, at all hours. Steven was terrified, not only of the pain, but also of what the seizures represented - that he was dying, that the end would be soon.

At their Monday morning staff meeting on June 24, hospice workers discussed Steven's case. He wasn't ready for death, they agreed. He was scared. They considered giving him heavier doses of drugs to diminish pain and fear and stop the seizures. That would make him less lucid, which was not acceptable. They concluded he needed more emotional support.

The hospice workers were worried that nobody in the family was acknowledging how close death was. He'd lost so much weight. His hands were stone-cold. And they worried that Linda was wearing herself out.

"He wants her by the bed at all times," said Nancy, the nurse.

The Rev. James Luckey, the hospice's pastoral-care counselor, decided to visit Steven that afternoon.

EARLY THAT SAME MONDAY MORNING, Steven grabbed his son's arm as he was leaving to go to work. Steven had dreamed during the night about a German shepherd wearing a gold chain.

"I want a German shepherd puppy," Steven demanded. "Bring one home."

Steven suffered in the knowledge that drug dealers worked his street, and that he was powerless to evict them. He was failing as a man. He wanted his son to become a man, not so much to take his place, but to feel this sense of duty, to protect and provide.

As Steven pulled up that afternoon, in his father's car, Gretchen looked out the window.

"There's no dog," she said. Her father, lying in his bed, was confident.

"Oh, yes, there is."

Gretchen looked again. "Ain't no dog."

She kept looking through the window.

"Oh, my God!" she said.

Young Steven walked in carrying a black-and-brown German shepherd puppy and a paper bag with dog treats and toys.

He put the puppy down, and off it scampered.

Steven lifted his head off the pillow and watched the pup. He smiled broadly.

"It took seven stores, but I got him," young Steven said. That made his father even happier.

Minutes later, the pastor, Mr. Luckey, arrived.

Sitting on the edge of the bed, close to Steven, the puppy nibbling at his cuffs, he asked about the seizures.

Tears streaked down Steven's cheeks, onto his pillow.

"I've been shot [as a teenager]," he said, "but there's no pain to describe what those seizures did."

"Steve," said Mr. Luckey, "sounds to me like it should be in the category of suffering, don't you think?"

"I pray every night and every morning. But Jesus won't have me."

The pastor drew closer. He had not expected a confession today.

"Is there anything in your life that separates you from the Lord?" Mr. Luckey asked.

"Yes."

"If you don't mind, Steve, I will hear your confession."

Linda sat next to his bed, stroking his arm.

Tearfully, almost inaudibly, Steven told a story of how the woman he loved - Linda, the woman he's lived with for 15 years, who cleans his bedpan; his best friend; his heart and soul; the mother of two of his children - is not his wife.

Steven was married to another woman. He had never divorced the other woman nor given Linda his surname. For that, he will never be right with her, never be right with Jesus.

He was worried that his legal wife, with whom he had had two children, would receive his life insurance and savings. All that, he told the pastor, would keep him from feeling peace on Earth, from entering heaven.

Linda was stunned.

"I never knew it bothered you so much," she said.

"It bothered me a lot. It was wrong. You've been a good woman always, but I haven't been a good man."

"Sounds like you want to do right by me, but God doesn't hold that against you," said Linda.

"I agree with Linda," said the pastor.

Steven shook his head in disagreement.

"If I forgive you," said Linda, "then God says it's forgiven."

Suddenly the living room was filled with light. The sun had fallen low enough in the sky so that its rays streamed through the blinds onto Steven, his bed, Linda, the puppy, and the pastor.

"I've heard those things that burden you," said the pastor, "that weigh you down spiritually. I'd like to offer a prayer. Linda has forgiven you. God has forgiven you. That drops it. We all miss the mark of perfection, Steve, and God understands.

"Let us all join hands," he said. "Thank you, God, for our lives, all the good things you have bestowed on each of us, good friends, that special loved one. I just ask you now, Lord, that you restore pardon and peace in Steve's heart. I just ask Lord that you could soothe and calm his troubled spirit. I ask that you continue to give him vision - you the great ophthalmologist that can restore the sight to the blind. Lord, I entrust Steve to your care. I just ask you to be with him and comfort him."

There was a moment of silence.

The room darkened again. Maybe from a passing cloud.

"Above all, buddy," said the pastor, "I wish you peace."

Steven seemed relieved, almost back to his cocky, confident self.

"I know you do, Rev," he said. "You bring out the best in me."

"I'm glad you allowed me to be here," said Mr. Luckey.

"You take the place of my grandma and my ma," said Steven. "You're the shoulder I lean on."

"Those are big shoes to fill."

It was nearly 6 p.m. Mr. Luckey had seen other patients that day. He stood, put on his jacket, and headed home to his wife and his chicken dinner.

Steven rolled on his side, and handed the dog a plastic-sausage chew toy. The dog inspected it for a few seconds, snatched it and disappeared under the bed.

HOSPICE WORKERS say they need more time to build relationships and trust, to solve problems, to help dying people accept their fate.

Mahoney, head of the National Hospice Organization, says doctors should refer patients to hospice earlier than they do. Patients on average die within 30 to 60 days after hospice is brought in. Fifteen percent live less than a week after starting hospice care.

"If you think about dying as being more than a medical event, . . . if you think about dying beyond that, then there is a role for hospice care earlier on," Mahoney said.

But many doctors are reluctant to refer patients earlier, because they don't want to admit defeat or because they find it difficult to deal with the family's grief.

And there's another problem. Enrollment in hospice requires a physician to say that the patient has less than six months to live, but doctors aren't good at predicting this.

About 80 percent of hospice patients have cancer, and their time left is easier to predict. Steven's oncologist, for instance, thought he had three months to live. But many more people in America die from heart disease, stroke, lung disease, and other chronic illnesses, and many of them are not eligible for hospice, in part because their doctors don't know how soon death will come.

"We need to completely restructure our health-care system for people at the end," says Joanne Lynn, director of the Center to Improve Care of the Dying at George Washington University. Lynn says it should be easier to get hospice-like services and more difficult to get useless medical intervention.

Savings from surgery and stays in intensive-care units, Lynn says, could pay for expanded hospice, which costs about $100 per day. Medicare and most private insurers pay for hospice care. Steven's hospice costs, which would total $3,000, were picked up by his hospice, which until recently relied on fund-raising to provide free care.

"Economics is going to push hospice ahead, regardless," said Christine Kriebel, director of the hospice program at Pennsylvania Hospital.

"But I don't want to see insurers pushing people into hospice like lemmings over a cliff. I don't think hospice should be the only option. But it should be one option."

STEVEN WAS A DIFFERENT MAN the morning after his confession. His breathing had become irregular. He was foggy, disoriented, drifting in and out. He couldn't eat. Even drinking the nutrition supplement Ensure was too much for him. Maryanne realized he had entered the phase that hospice workers call active dying. This was the end.

Linda couldn't believe it. He had seemed so alive the night before.

"I think on Monday night he made peace," she said. "After that, he was ready to go."

He grew worse on Wednesday.

When John arrived, he drew Linda into the kitchen.

"His breathing has changed," the nurse said. "His liver is starting to enlarge from the tumor, and his diaphragm, which he uses to breathe, can't become fully enlarged. He's more confused, because of decreased oxygen to his brain. His urine will decrease. His appetite will decrease. He could die tomorrow. He could die in a week."

Linda didn't flinch.

"He knows he's dying," Linda said. "I know he's dying." After he dies, she said, "then I can break down and cry."

Together they walked back to Steven.

Slurred, drugged, dying, he still knew right away what to ask.

"What'd you tell her? - you better tell me."

John repeated what he'd told her, that Steven had stopped eating and his breathing had changed.

"These changes signal you're actively dying."

Steven fought back the only way he could.

THE NEXT DAY, THURSDAY, JUNE 27, a lawyer went to the house.

Maryanne had given Linda a number for the Philadelphia Bar Association referral service and encouraged Linda to call to establish who would get Steven's worldly possessions.

That afternoon, on the day he was called, Ira Mazer from Port Richmond walked in - wearing a blue shirt, tie, and black wing tips. He waived all fees.

Steven lay in bed, in red-and-white striped boxers, one tube leading from his liver, another out his boxers. His eyes were half-open.

"I need to establish you're of sound mind," the lawyer explained. "Do you know where you are?" There was a long pause.

"Home."

"Do you know who this is?" He waited.

"Linda."

Linda said it was time for a seizure pill. She put it in Steven's mouth and offered him a drink, which he wouldn't take.

"Did you swallow it?" Another wait.

Steven stuck out his tongue and showed Linda, defiantly yet lovingly, that he had.

"I believe you're pretty with it," said the lawyer.

So he began.

"Have you thought about who you want to get your stuff?"

The lawyer was talking slowly, as if to a child, but Steven was out of it.

"He's talking to you, Steve," prodded Linda. "You going to answer him? Wake up."

"Who do you want to give it to?" repeated the lawyer.

"To Linda," he whispered. He pointed to her.

"Great," said the lawyer. "Do you want anybody else to get anything?"

Silence.

"My son, Steven."

"OK. And what does Steven get?

"My car, my car."

"And what kind of car do you have?

Long silence. The lawyer realized this was a silly question to ask a dying man. After all, the car was parked right outside. He continued, "And Linda gets everything else?"

"Topaz," said Steven. "'87 Topaz."

"Is there anything else?"

Steven waved the lawyer closer. Barely audibly, he said, "A divorce.... Want to get married."

Linda shook her head.

"You're too sick, and it takes too long," she said.

"Even an uncontested divorce wouldn't come through for at least two and a half months," said the lawyer. "Money could probably be used better elsewhere."

The lawyer had what he needed. He returned with a will two hours later. Too weak to sign his name, Steven wrote an X.

IN THE EARLY-MORNING HOURS OF FRIDAY, Chris Jacobs, 48, sat next to his brother, Steven, and read him the Psalms. Steven drifted in and out.

At 2, Steven woke up. He couldn't drink from a straw anymore. Linda wet his lips and tongue with a green mouth swab.

She knelt beside him.

"I'm happy," he told her. "I'm tired."

"You prepared me for this," she said. "You prepared me every step of the way."

Steven winked.

"I'll be all right," she said. Steven and Linda kissed. Brother Chris and sister Nadine hugged him, then young Steven and Gretchen.

Linda went outside and saw a bright star in the night sky. It was a sign. She went back inside.

"There's a bright star over this house," she said. "It's not moving. It's your mother coming to take you home."

"I gotta get up," Steven said.

"And go where?" Linda said incredulously. Steven hadn't been out of bed in a week.

"To the couch," he said. "I'm not dying in no hospital bed."

Chris put fresh pajamas on his brother. Nadine put a sheet and blanket on the couch by the window. Then Chris carried Steven like a bride over the threshold, over to the couch, where he drifted off to sleep.

Chris continued to read Psalms.

About 6, Maryanne and John arrived.

Young Steven and his mother were sleeping in the hospital bed - her head at one end, his at the other. Chris was asleep in one chair, Nadine in another. Gretchen was upstairs. The cat was sprawled on the wooden floor. The puppy was at a neighbor's.

On the coffee table was a bag of green mouth swabs, a few of them used. Two Bibles, one opened to Mark 15, the other to Psalms 53. A Polaroid camera. A plastic urinal. Toilet paper. An ashtray with butts. Morphine. A Pepsi. Dilantin. Two beer cans.

Maryanne knelt beside Steven. She held his hand, stroked his head, whispered in his ear.

"Your family is with you now. That's what you wanted. And we're asking God to help you. You've got one strong woman."

John checked his breathing and vital signs.

"Completely nonresponsive," John said. "He's going to die within 24 hours."

Young Steven, awake by then, started sobbing in the hospital bed. Linda comforted him. "Daddy's not going to be suffering anymore. You go ahead and cry. It's good to cry."

John gave Steven a few drops of medicine from a dropper. "This will help you breathe easier," he said.

"You've done a great job, incredible," John told Linda.

The morning progressed. Linda, John and Maryanne sat or knelt next to Steven.

"Death is very undramatic," Maryanne said. "Slow. Waiting. I don't know why, but in movies they dramatize death so. But in real life, it's a slow pace. Not big fireworks."

A day later, Saturday morning, Steven opened his eyes. He looked at Linda. She was holding his hand. He squeezed her hand. She told him she loved him.

A few hours later, he stopped breathing.

Gretchen noticed first.

"Oh, man," she cried. "He's died."

Linda kissed him. Gretchen kissed him.

The house was filled with family, and more visitors came, including the hospice workers and Steven's wife and other children.

The hearse arrived about 4 p.m. Steven had been with hospice for 31 days.

Linda sobbed all afternoon.

THE FUNERAL WAS SUPPOSED TO BE the next Saturday.

The night before, at 9:30, Linda called Maryanne in a panic.

The funeral director, who was charging $5,000, was willing to wait for payment, but the cemetery wouldn't cover Steven with one shovel of dirt until Linda had paid in full - $1,250.

Linda was $450 short.

Maryanne calmed Linda. "I'll take care of it."

She worked out this solution: Linda would give the cash she had to the cemetery director, and the funeral director would write a check for the balance, tacking it onto his own bill, to be paid when the insurance money came in.

Maryanne and John attended the funeral. They sat in the back row.

James Luckey gave the eulogy. Steven had wanted that.

After the funeral, out in the bright morning sunlight, Linda seemed more spirited than she had in weeks. She gave Maryanne a big hug. As she climbed into the limo for the ride to the cemetery, she turned to Maryanne one last time.

"Don't forget about me!" she called. "I want to see you!"

"Don't worry," promised Maryanne. "You will."

EPILOGUE: Maryanne called Linda often and saw her a few times.

Steven and Gretchen were beneficiaries of their father's insurance policy, and each received a small sum after the funeral bills were paid. Gretchen is sure her father is smiling down on her. She bought a car, learned to drive, and enrolled at Temple.

The dog, Remus, is beloved by all - but still chews everything in sight.