Hospice Care by Mitigare

Results and plans 2018 to 2019


Dear Friends,

With great pleasure, I am able to report that 2018 was a very good year for Mitigare. We were able to serve 26 patients. We This is a substantial increase over our average patient load in 2017.

Our financial model for sustainability has proven to be sound. Only five patients of the 26 were able to pay the full price for services received. However, patient income did cover 36% of our overall expenses. We continue to be very timid of incurring any expenses outside of patient services and professional staff development.

Our medical director, Dra. Tejeida and our President, Martha Hamill attended the International Palliative Care Conference for the Latin-American Association of Palliative Care in April. We were able to send three of our nurses to an International Palliative Care Conference hosted by the National Institute of Cancer (INCAN) in May. Dra. Tejeida provided three full day training courses to our nurses to improve their End of Life nursing skills.

Here are some of the summary statistics for 2018:

  • 26 patients served

  • 83% Number of patients receiving financial assistance

  • 209 Number of doctor visits to patient homes

  • 64 Number of nurse visits to patients

  • 29 Number of social worker/thanatologist visits

  • 30 Number of group bereavement sessions hosted

  • $366,000 pesos billed professional services

Our fundraising efforts in 2018 were satisfactory. Several individuals and one USA based hospice foundation made extraordinary efforts to help us achieve this.


                Patient Assistance Fund Donations                                  $306,505

                Unrestricted Donations                                                      $  83,612

                Grant Income for Equipment (SMCF)                               $  30,260

                Grant Income Unrestricted                                                $226,394

                Grant Income for Education/Prof. Development           $178,307

                Total Fundraising Income                                                  $825,078



Mitigare depends on public support to allow us to provide hospice care to those patients and families that cannot pay all of the cost of their medical care. We also depend upon you to provide for education and capacity building. Our ordinary income is sufficient to pay all administrative and miscellaneous costs. We were able to complete 2018 with a moderate surplus. To achieve our goal of serving 50 patients in 2019, we will need to raise more than the previous year.

Our biggest barrier to having the “statistical” patient load we should have is lack of awareness that hospice is available in San Miguel. We will begin a comprehensive outreach program this month thanks to a special grant received from the Shaaron Kent Foundation. Our goal in 2019 is to serve 50 patients.

In May of 2019, we will be hosting a 3-day International Hospice Conference in San Miguel directed to medical professionals throughout Mexico. Hospice is still struggling to get a foothold in Mexico. (In fact, we are one of only two private, nonprofit hospices in the country!). Building capacity within the general public hospital systems in Mexico is an important part of our mission. We have grant income committed to cover any costs above the tuition and fees income we will receive.

For additional information, please contact Lee Carter, Treasurer  contacto@mitigare.org

Rotary Donates Home Care Equipment to Mitigare

In the summer of 2016, the Rotary Clubs San Miguel Midday and Walla Walla, Washington joined forces to supply Mitigare with the home medical care equipment needed to provide in-home hospice services. Mitigare now has 6 hospital beds, 3 oxygen concentrators, 3 wheel chairs, and other equipment to provide our patients with quality home care.

The Evolution of Hospice Care in Mexico

The first hospice, specialized care for persons with end-of-life illnesses, was founded by Dame Cicely Saunders in England in 1967. Dame Saunders began her career as a nurse in World War II. When she realized she could not successfully begin to treat patients with severe end-of-life pain as a nurse, she returned to medical school to get her medical degree. The first hospice was named after St. Christopher, the patron saint for travelers. 

In 1969 Dr. Elisabeth Kubler-Ross wrote On Death and Dying. This book was based on more than 500 interviews with dying patients. With this additional social science added to the medical work already being done by Saunders, hospice became a medical specialty with the goal of treating the patient and his family medically, psychologically and spiritually.

Within several years the hospice concept was being implemented throughout England and, soon thereafter, throughout Europe, the USA and Canada. The first hospice in North America was founded in 1974 in Bradford, Connecticut. Hospices continued to expand across the United States and the ‘hospice benefit’ was created provisionally by Congress in 1982. The Medicare hospice benefit was made permanent in 1986 and it became a nationally guaranteed health benefit under President Clinton in 1993.

Mexico was not far behind in recognizing the need for an end-of-life specialty in treating cancer in its last stages. Dra. Silvia Allende, Mexico’s palliative medicine pioneer, began her work in the National Institute of Cancer in 1992. She is the author of many publications and investigations and is rightly recognized as one of the leading hospice specialists in Latin America. Dra. Allende has worked to bring hospice-type care to all of Mexico’s specialty level 3 cancer hospitals since that time. Dra. Allende is Mexico’s Cicely Saunders. In 2002, Nurse Beatriz Montes de Oca founded the first, nonprofit Mexican hospice in Guadalajara operating with the same philosophy of care as Hospice St. Christopher’s in England.

Hospice in San Miguel: In 2007, only 9 years ago, if you were diagnosed with a terminal illness in San Miguel de Allende with a prognosis that would lead to a likelihood of pain and awkward symptoms, your only option was leaving your home in Mexico to return to your expatriated country. Today in San Miguel, you can rest assured that whatever diagnosis and prognosis you have can be addressed right here in San Miguel in the comfort of your home, surrounded by family and friends.

There have been several attempts to establish a hospice organization in San Miguel de Allende over the years. Early efforts failed because of the lack of morphine and basic knowledge in treating the severe pain often associated with certain illnesses. These valiant attempts by St. Paul’s church and the Unitarian Universalists brought much care and comfort but little medical relief. Hospice is and always will be 90 percent medicine and 10 percent love.

In 2007 Hospice San Miguel (HSM) was founded as a nonprofit organization with the mission to create a full-service hospice that included the medical specialists to do the heavy lifting of pain and symptom control. This hospice established standards of care that were exactly the same as those of hospices in the United States and Canada. It was a difficult journey, but HSM solved medical management problems by providing training to local doctors in pain management and symptom control. Morphine and other essential medications were made available in the quantities necessary to provide effective pain and symptom management. The hospice concept was foreign to the general Mexican population, so Hospice San Miguel instituted programs to create awareness, not only within the medical community but also with the general population. Many hundreds of persons were able to achieve a ‘good death’ with enhanced quality of life because of Hospice San Miguel’s work. Medical workers in San Miguel - doctors, nurses, and caregivers - were trained.

Hospice San Miguel teamed up with the End-of-Life Nursing Education Consortium (ELNEC) in 2010 to bring a three-day conference to San Miguel de Allende. It was attended by more than 100 doctors, nurses and social workers. ELNEC is the most important hospice training program in the United States and is run by the American Association of Colleges of Nursing (AACN). ELNEC today is the worldwide standard of excellence in hospice training. Dr. David McGrew, a renowned hospice doctor, also came to the ELNEC conference to work specifically in a separate curriculum with physicians on pain and symptom management. Finally, San Miguel had the capacity, the skills and the medicine needed to provide quality hospice care.

Dr. Roger Strong, a nurse practitioner with San Diego Hospice, returned to San Miguel several times to continue raising the skill levels of Hospice San Miguel’s team using ELNEC as his resource. Eventually six persons in San Miguel were designated ELNEC train-the-trainers with authority to teach the ELNEC curriculum to other medical specialists in Mexico.

The importance of training and education has become more and more apparent in establishing a hospice culture within the medical community throughout Mexico. In 2011 the Rotary Club of San Miguel de Allende - Midday, which supported Hospice San Miguel with more than $20,000 USD in grants, and the Rotary Club of Staunton, Virginia, teamed up with private benefactors to work with Mexico’s national institute of cancer (INCAN) and Dra. Silvia Allende. In the fall of 2011, an ELNEC mini-course was presented at Dra. Allende’s principal hospital in Tlalpan, CDMX. From this a plan was formed to expand this training for a full scale ELNEC presentation at the annual INCAN conference in Puebla the following year. Also, for the first time, Hospice San Miguel simultaneously brought the Northwestern University Feinberg School of Medicine’s Education in Palliative and End-of-Life Care Program (EPEC), to teach doctors about hospice care. One hundred doctors completed the EPEC program and one hundred nurses and social workers completed the ELNEC program. Fifteen ELNEC students obtained train-the-trainer status by the end of that conference.

Through this new alliance built with INCAN, the HSM Medical Director, Dra. Maria de Lourdes Tejeida was selected to take a 12-month internship at INCAN’s primary hospital in Mexico City. She completed that internship and obtained the new specialist license and degree in palliative medicine from the Secretaria de Salud. So, San Miguel enjoyed having one of the nation’s most qualified palliative physicians living in San Miguel.

Unfortunately, Hospice San Miguel’s success was also the reason for its failure. As the operating plan for Hospice San Miguel was to provide full hospice care to all persons at no cost, it was unable to sustain itself as the hospice patient population continued to expand. By 2014, HSM was attending to close to 180 persons per year. The annual cost for providing care became unmanageable, and HSM closed its doors in June of 2014.

But, do not despair, as there are many residual benefits that San Miguelenses enjoy from the investment made in our community by the supporters and benefactors of Hospice San Miguel. We have a population that is aware of the need for quality end-of-life care. Dra. Tejeida, on returning from INCAN, was able to set up a hospice unit at the local Hospital General with three dedicated beds and services covered by Seguro Popular. Although the practice of hospice was generally unnoticed by the expat community in the last two years, Dra. Tejeida treated more than 500 patients through the Hospital General system. It should also be noted that this is one of the first general hospitals in Mexico to implement a hospice program as part of its standards of treatment. Dra. Tejeida was also given the responsibility for palliative medicine training throughout the Region II Health District under the Secretaria de Salud of Guanajuato. Dra. Tejeida has continued to teach hospice care locally to the doctors, nurses and social workers at Hospital General. The capacity and skills have continued to expand even since the demise of Hospice San Miguel.

Hospice has become a passion for Dra. Tejeida. She understands all too well that even though the HG palliative care program was great and serving a large part of the San Miguel community, that there are still many others without access to hospice. Hospital General has not been able to offer home hospice for those who wanted to die in their own homes surrounded by family, friends and, yes, their pets. It has been her dream to establish a new hospice in San Miguel where all persons regardless of their country of origin, financial capacity or health insurer can expect and receive hospice care for themselves and their loved ones in the comfort of their own homes.

Over the last four years, Dra. Tejeida has worked closely with Mtra. Martha Hamill, a trained thanatologist and expert in bio-ethics. Thanatology is the study of the science of dying including the psycho-social problems accompany dying persons and their families. They have worked together to establish the bio-ethics committee at Hospital General and have traveled together to various parts of Mexico to train in hospice care and medical ethics. Mtra. Hamill has been providing bereavement counseling and directing bereavement groups at St. Paul’s Church for the last four years in both English and Spanish. Hamill also has become a passionate promotor of hospice care.

Finally, Dra. Tejeida’s dream has become a reality with the founding of Mitigare Cuidados Paliativos, A.C., a legally established Mexican nonprofit organization. Dra. Tejeida is the medical director, and Martha Hamill is president and resident expert in treating psycho-social issues surrounding death. Mitigare has been able to keep all of the good that came out of Hospice San Miguel. It has developed an operating plan that promises to be self-sustaining. Incredibly, every person on the Mitigare staff – doctors, nurses and social workers – have taken post-degree courses and diplomados in hospice care. Mitigare represents the cream of the cream of hospice experts in San Miguel. The level of service Mitigare is able to deliver is of a world-class standard. Mitigare has carefully constructed its operating plan so that all persons can receive care regardless of financial capacity. All patients are evaluated upon intake by the Mitigare social worker to determine where they fit on a sliding scale determination of capacity to pay. Be it $1,000 pesos or $20 pesos, everyone has the dignity of paying for the services they receive. Mitigare has obtained a grant from the Rotary Club of San Miguel - Midday and the Noon Rotary Club of Walla Walla, Washington, to obtain all of the medical equipment necessary to provide home hospice care. Mitigare is in the process of raising additional startup funds for a few more capital purchases, and it is establishing a Patient Assistance Fund to help support services to economically challenged patients. Help Mitigare establish itself if you can by helping to establish the assistance fund.

Mitigare, like the mythological phoenix, has been reborn from the ashes of Hospice San Miguel to be stronger and better. To the many people in San Miguel who were staunch supporters of Hospice San Miguel, know that your investment has paid great dividends.

by Lee Carter, December 2016

Mitigare: Hospice and Palliative Care      
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