Compassionate, informed advice about healthcare decision making

Archive for the ‘Advance Care Planning’ Category

How Come so Much Aggressive End-of-Life Care?

Posted by

Photo by Vidal Balielo Jr. via Pexels.com

The man was riddled with cancer. The paramedics continued CPR as they wheeled him out of his nursing home room. I drove his wife to the emergency room. This is what the family wanted, although I am not sure the patient would have chosen it. When the doc came to the waiting room to tell the family he died, they congratulated themselves on “trying everything.”

Sadly, aggressive care in the last days of life is all too common. Perhaps, my experience with this patient was an extreme example. Aggressive care can include an ICU stay, surgery, chemotherapy or radiotherapy. New research shows that about 60% of elderly Americans with metastatic cancer receive some sort of aggressive care in the last 30 days of life.

60% of elderly, advanced cancer patients receive aggressive life-saving attempts in the last month of life

Photo by Matej via Pexels.com

This research was recently published in JAMA Network Open and looked at the last 30 days in the lives of 146,329 people who were over 65 and had a diagnosis of metastatic cancer, in other words, very sick, frail elderly folks with an average age of 78.2 years.

I was put onto this research by a great article from Paula Span in the New York Times. She writes a regular piece called, “The New Old Age,” and this was one in her series. What is not clear from the research is “Why?” Why are so many, obviously dying old folks being dragged through more treatments which are normally reserved for those seeking cure?

Some may want this treatment, but I doubt it

Photo by Kampus Production via Pexels.com

It is true that some of these aggressive treatments can be considered palliative, for example, radiation to reduce the size of a tumor and hopefully reduce pain. It is also true, that some of this aggressive treatment is actually what the patient wanted. Perhaps, they were made fully aware of their grave condition but chose treatment that had little chance of helping them. Both of these possibilities are probably in a small minority of this aggressive care.

Spirituality raises its head again

The JAMA study concluded, “The reasons for aggressive end-of-life care are multifactorial, including family involvement, religion and spirituality, patient preferences, patient-clinician communication, and health care delivery systems.” I would add, the default mode in our healthcare system is to do stuff, when faced with a problem. That “stuff” is usually doing more of the same rather than shifting to comfort care only.

My chaplain antennae always perk up when I see “religion and spirituality” mentioned in any medical journal article. I am back to my oft-repeated premise — for patients and families, end-of-life decisions are primarily emotional and spiritual. People need to learn when it is time to let go and just let things be.

_________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

In Hospice, Jimmy Carter is NOT Giving Up On…

Posted by

As I write this on February 24th, former president Jimmy Carter is at home under hospice care.

The popular story is that Carter had a failed presidency, but post-White House, he was the most successful ex-president ever. Now, 42 years after suffering a landslide defeat to Ronald Reagan, some have changed the first part of that narrative by seeing strength in his single term in office.

Place: Savelugu, Ghana, Date: Feb. 8, 2007, Credit: The Carter Center

In his years after leaving Washington DC, Carter traveled the world serving the poor by bringing healthcare to underserved areas and building houses. His work also included building democracies by helping nations hold free and fair elections. Oh yeah — when he was home in Plains, Georgia, he also taught Sunday school at the Baptist church.

I expected the media to perpetuate a hospice misconception — one of my pet peeves — and they did not disappoint. On ABC World News Tonight this past Monday, David Muir read the teleprompter, “Carter will forgo medical intervention receiving hospice care at home.” I felt like yelling at the TV, “Hospice care IS a medical intervention.” But I didn’t.

Even the announcement of this news from the Carter Center alluded to this mistaken belief. “After a series of short hospital stays, former U.S. President Jimmy Carter today decided to spend his remaining time at home with his family and receive hospice care instead of additional medical intervention.”

Here is what this unfortunate wording insinuates: You seek medical care for a cure. You give up medical care and choose hospice care when you are dying.

Hospice care is one of the best medical interventions you can have. Hospice focuses on the patient, not the disease. The goal is to comfort by any medical means necessary. Hospice care also concentrates on supporting the family as well as the patient.

Place: Austin, Texas, Date: 2014, Credit: LBJ Library

The Carter Center’s announcement also reveals how so many people turn to hospice “After a series of short hospital stays.” I don’t know if these hospital stays were for treatment of the former President’s cancer or if he had another fall. Often when a patient is aging, frail, and seriously ill, patients and their families will eventually conclude, “No more trips to the hospital.”

This is how it should be. There is nothing wrong with seeking medical intervention at the hospital when needed. I also know that some people go to the hospital to die, not wanting to burden the family by dying at home. But most people say they would rather die at home with their family gathered around them if given a choice.

Thank you again, Mr. Carter, for showing us a way to peace.

Cover photo: Place: Nasarawa North, Nigeria; Feb. 15, 2007; Credit: The Carter Center

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

New, New Year’s Bucket List

Posted by

I’ve never been one for a “bucket list.” You know — the one with skydiving and climbing Mt. Kilimanjaro on it. Never thought of those things.

But, I do think of “things to do”. They come to mind, and I say to myself, “I really need to do this before I get so disabled or demented that I can’t finish them.”

For what it’s worth, here are some of mine.

  • Update our wills. It has been years since we last did this. We’ve moved to a new state—TWICE—Florida and now Mississippi. We’ve launched our daughter out from under our roof (never out of our hearts). There have been many other changes in our situation that make this update necessary.
  • Update our advance directives. I wrote a blog recently about Voluntary Stopping Eating and Drinking (VSED) by advance directive. I want to add instructions on when to stop hand feeding me if I have advanced dementia. Putting this in writing can be very easy to do with samples I linked in the blog. Then, of course, we need to have two friends over to witness my signature.
  • Review beneficiaries on retirement accounts. This one we have done recently but I’ll check again just to make sure they say what I want them to say.
  • Continue to gather my “memoir” for my kids and grands. I wrote a blog around my birthday in 2021 about “keeping your regret list short.” It was kind of a “bucket list” thingy and I mentioned the notebooks I had gathered for my children and their children. Well, I have written more since then, so I need to keep on gathering. I also print my favorite quotable-quotes file (36 pages long). Interestingly, I found among dad’s papers, a notebook he kept of his favorite quotes, probably dating from the 1950s. When I started my own compilation of quotes, I had no idea he had done the same.
  • Finish my “spiritual autobiography.” I am in a small group at church, and we all are writing a spiritual autobiography to share with the group. I have a draft and will continue of refine it. I want to get it in a form suitable to give a copy to each child and grandchild. My spiritual life is so central to who I am, and I want to let those who love me know what is bubbling up inside. I don’t think they have any idea.

These are all doable items — and so important to me.

What about you? What’s bubbling inside on your important “things-to-do” list.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

Does Hospice Hasten Death? Some say “yes”— Most say “no”

Posted by

Boy, was I blindsided?

I posted a quote from a study that examined the general public’s understanding of hospice on my Hard Choices for Loving People Facebook page. 30% of the respondents said they felt hospice hastens death. My Facebook post got hundreds of likes and comments, a lot of traffic for my humble page. I had no idea this would engender such a strong response.

“This morphine is wonderful”

Misconceptions can be based on misconceptions. When people hear that a friend is receiving morphine, they automatically think death is near. Not necessarily. Because of this close association of morphine with death and the association of getting on morphine in hospice, many assume that’s what hospice does — hastens death. Not so. Morphine controls pain and relaxes breathing.

I had an elderly patient once who was dying of respiratory failure. She was so short of breath that it was a major chore for her to move from her bed to a chair. She got great relief from morphine which she took for months before dying. She told me once, “I’ve always been opposed to drugs, but this morphine is wonderful.”

The coincidence of death after morphine

Many of the respondents to my post who agreed that “hospice hastens death” told stories of family members going on hospice and dying soon after. Why should this surprise us? Hospice requires that a patient is within six months of dying, although the average patient is only on hospice for two weeks.

I am sure it is just a coincidence that a patient receives a dose of morphine and dies shortly after. The family then thinks, “she died because they gave her morphine.” She did not. She was on hospice because she was dying, and she just happened to take her last breath after taking morphine.

No incentive for a hospice to hasten death

It makes no sense that hospice would want to hasten a patient’s death. The more days the patient is on hospice, the more reimbursement the hospice receives. It is totally against their financial interest to hasten death.

Hospices also want to make sure their patients are as pain-free as possible. Families of hospice patients fill out surveys after the death of their person. They rate the hospice on pain control, among other items.

So, yes, hospices use morphine to keep patients comfortable, not hasten death. They want to have the patient as long as a natural dying process will allow, and they want favorable survey results.

The research is clear; patients live longer on hospice

Many studies confirm that hospice patients live longer than nonhospice patients suffering from the same disease. One study looked at dementia patients. On average, the patients on hospice lived longer than those who never entered a hospice program.

Another study looked at five different kinds of cancer and congestive heart failure. Once again, the patients who were under hospice care lived longer than the nonhospice patients.

So, rest easy. If you have a life-limiting illness and want to live longer with a better quality of life, go into hospice as soon as possible.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

VSED by Advance Directive — An Alternative to Prolonged Dying

Posted by

Margot Bentley

Margot Bentley did not want to spend her last days in the way she spent her last days. Hers was a fate almost all of us wish to avoid. She told her family her wishes, and she put them in writing. Yet, Voluntary Stopping Eating and Drinking by Advance Directive (VSED by AD) did not work for her.

In my last blog, “She Fasted to Hasten Death — VSED,” I introduced the idea of VSED. It is a legal and morally acceptable way to hasten death when faced with a terminal or chronic illness one finds unbearable. This option is only open to people with the presence of mind to notice that they are in a state they would consider intolerable.

As a nurse, Margot Bentley cared for many patients in the advanced stages of dementia. She let her family know, and put it in writing, that if she ever progressed to severe dementia, she would like hand feeding withheld to allow her to die a natural death. When that time came, her family asked the care facility to honor their mother’s wishes and stop the hand feeding.

The facility refused, saying that Mrs. Bentley indicated she had changed her mind because she opened her mouth and received food offered to her.

Advanced-stage dementia patients may:

  • Require around-the-clock assistance with daily personal care.
  • Lose awareness of recent experiences as well as of their surroundings.
  • Experience changes in physical abilities, including walking, sitting, and — eventually —  swallowing.
  • Have difficulty communicating.
  • Become vulnerable to infections, especially pneumonia.

Source: “Stages of Alzheimer’s,” Alzheimer’s Association website

Everyone I know would like to avoid ending their days lying in a nursing home bed, unable to recognize family, dependent on others to wipe their bottoms, and help with all activities of daily living. People can live for years in this final stage of dementia. I have told my family to stop hand feeding when my time comes.

Margot Bentley’s family had to navigate the court system in British Columbia to try and comply with their mother’s expressed desire. The courts denied their request.

VSED by AD: A new frontier of end-of-life care

I have been chaplain for several patients who were allowed to die a natural death after the cessation of hand feeding. The families were convinced that their person would not want to be sustained by even hand feeding. Their deaths were peaceful within days of the withdrawal of food and water.

From: End of Life Choices NY advance directive

All these patients were in the most advanced stages of dementia. Even hand fed, these patients would probably not have lived more than a few months. I would have felt better had the patient left written directions, such as a living will or other advance directive. But these families felt certain they were requesting what the patient would have wanted if they could have spoken.

Here are links to three websites that provide information on VSED by AD; each includes a sample form:

End of Life Choices, New York

Final Exit Network

The Dartmouth Dementia Directive

I personally would like to avoid a prolonged dying from dementia. I want to spare my family the expense and emotional toll of watching me die by inches. I know it will be hard to invoke my advance directive, yet, they will have confidence that this is the way I want to go.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

She Fasted to Hasten Death — VSED

Posted by

Rosemary Bowen was not terminally ill. She hastened her death by fasting. It took seven days.

Ten states and the District of Columbia allow for “medical aid in dying” (MAID). In those jurisdictions, terminally ill people with six months or less prognosis can get a prescription for a lethal medication in order to hasten their deaths. But what about patients not in one of these states or those whose life expectancy is greater than six months? VSED is an option.

Voluntarily Stopping Eating and Drinking (VSED) can be practiced by those seeking an earlier death. It’s what Rosemary did.

Rosemary Bowen, at 94, was living independently. She said she had had a wonderful life and did not look forward to a long, slow decline toward death. For years, she had been telling her children, “That her life would not be worth living if she had to depend on caretakers to feed her, dress her, and take her to the toilet.” Then, it happened. She fractured her back and went to rehab but was unable to live independently. That was enough for her.

Rosemary asked her daughter to video her so she could show others how to take control of their dying with VSED. The 16-minute video is available on YouTube.

VSED is a legal and, in my view, a morally acceptable way to end one’s life. It is based on several established principles in medical ethics. Affirming “autonomy” we allow patients to make decisions to reject any medical treatment — even treatments that could potentially save one’s life. Also, medically-supplied nutrition and hydration (for example, by a feeding tube) have long been understood to be a treatment that could be refused.

What Rosemary did was take these one step further as she choose to refuse food and water. She did this basing her decision on her own values:

  1. She valued independence above all else. Being dependent on others was an unacceptable quality of life.
  2. She did not want to be a burden on her family.
  3. She did not want to go the route of many of her friends who spent years declining in assisted living or nursing homes, facing one medical setback after another.

The importance of medical support during the process

Do not try this without medical support. Rosemary was able to get a hospice to care for her in her last days. Palliative care is also available to ease burdensome symptoms like pain and thirst. See “VSED Resources Northwest” for help with choosing this option.

“I am leaving life with great joy,” she says in the video. “I can’t tell you how content I am. I recommend it highly to do it this way.… The price of staying alive is having to live without quality and joy.… I feel so privileged to be exiting life like this and think of all the people who are wringing their hands and saying if only God would take you and all they need to do is give God a little help by holding back eating and drinking.”

At one point in the video, she is on the phone saying goodbye to friend. As she signs off, she says, “I’ll see you in heaven.”

Indeed.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

I’m On a Podcast This Week

Posted by

I am interviewed by Dr. Saul Ebema on the “Hospice Chaplaincy Show” this week. He has a great podcast for hospice chaplains that I listen to regularly. Click here for access to the show.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

Canada vs. U.S.A. at the End of Life

Posted by

Me: “Hello, this is the chaplain, Hank. I would like to come by your home for a visit Tuesday, at 10. Would that work for you?”

Patient: “Oh, hi… (pause) No, not then. How ‘bout Thursday at 10?”

Me: “Great, see you then.”

I thought of this conversation as I was digging down into a Canadian governmental report.

Why are we so different than our Canadian neighbors? We share a 5,525-mile-long border yet, in response to one question, we are miles apart. Do we really live and die that differently?

I have this nerdy side of myself. I read through medical journal articles and government reports looking for insights into all things end-of-life. The government of Canada and the State of Oregon recently released their annual reports on Medical Assistance in Dying (MAID) or, in Oregon, Death with Dignity. These are the rebranded names for what used to be called Physician Assisted Suicide.

One number jumped out

End-of-life concerns: U.S.A.

End-of-life concerns: CANADA

I’m reading through these reports and one number jumped out at me. Physicians who aided these terminally ill patients in hastening their deaths with medications were asked, “Why did the patient want to end their life by taking a lethal medication?”

In Oregon, the number one reason out of seven choices that patients gave was concern over “Losing Autonomy.” 93.3% of these patients listed that as one of their end-of-life concerns. In Canada, at the BOTTOM of a list of eleven possible concerns, “Loss of control / autonomy / independence” is only mentioned by 1.7% patients.

My interest was piqued by that “autonomy” difference. So, I contacted my friend, Tim Ward, who is now writing about his travels in Europe. He and his wife are taking “senior gap year” as in “senior citizen gap year” traveling. Tim is a Canadian by birth and has recently become a U.S. citizen.

He emailed back from Paris, “It might be that in Canada, autonomy is less of a value than, say, meaningful social connection” and “the rugged individualism of the West is part of eastern Oregon’s make up.”

Individualism/Autonomy vs. social connection

I think he is on to something here. For example, the social connection vs. autonomy shows up in how we provide healthcare. In the U.S. we do not provide universal healthcare, Canada does. There is no for-profit health insurance industry in Canada, yet everyone has access to healthcare. The U.S. system is built upon a for-profit system that leaves 8.6% (28 million) of our fellow citizens without health insurance. How we provide healthcare is just the most glaring example of how we value individual choices over the common good. Also, the social safety net is very weak for the poorest among us in the U.S. — as we witnessed in the pandemic.

I got curious about where in the world people are the happiest. Turns out, Canada (#15) and the U.S. (#16) show up next to each other in a recent ranking of the happiest countries. The top countries are in northern Europe.

From the Gallup World Poll report, “[Finland] and its neighbors Denmark, Norway, Sweden and Iceland all score very well on the measures the report uses to explain its findings: healthy life expectancy, GDP per capita, social support in times of trouble, low corruption and high social trust, generosity in a community where people look after each other and freedom to make key life decisions.”

Critics would say that’s true, they may be happier, but they pay very high taxes. The countries highest on the “Happiest” list are often labeled as “socialist” by those same critics. That’s a discussion for another time and place. The point here is that the autonomy cherished by U.S. citizens shows up in less “social support.”

The myth of the cowboy

Photo by Taylor Brandon on Unsplash

Tim’s other point, about “rugged individualism,” caught my eye because of another nerdy side of me — I read books about the American South and how we got the way we are down here. Currently, I am into How the South Won the Civil War: Oligarchy, Democracy, and the Continuing Fight for the Soul of America by Heather Cox Richardson.

Richardson is a historian with 1.6 million followers on Facebook. She writes on that platform often and produces long videos discussing various history-related topics. In this current book she explains the growth of the “myth of the cowboy,” the ultimate “rugged individual.” According to her, since the late 19th century, Americans have bought into this idea that anybody can attain whatever they want, that this country was built by autonomous “rugged individualists.” This is a myth because wealth actually went to a few elites from the days of the Founders to today.

Our founding documents lay out this contradiction in spades. The same property-owning White men who wrote, “All men are created equal,” enslaved Black people and did not give women or poor Whites a vote. We, as a nation, have been struggling with this contradiction ever since. Although Canadians do not have the history of slavery we do, we both share shameful treatment of indigenous peoples. Also, a discussion for another time and place. The point here is lionizing the “rugged individual” can show up as valuing autonomy at the expense of social connection.

Pastoral care at the end of life and autonomy

The phone exchange with the patient was typical of many we had over the months I was his chaplain. He ALWAYS chose another time. As a chaplain for those at the end of their lives I am always looking for ways to enhance autonomy, because I know it is so important to most of us. I gladly changed my plans. I figured this was my little way of affirming his autonomy.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

“How effective is chemotherapy?” — That is the Question

Posted by

Would you spend $100,000 on a cancer treatment with many painful side effects that might help you survive 6.24 months as opposed to 5.91? That is 10 days longer in greater pain and suffering?

What if the doctor told you just that “this treatment will help you survive longer”? This is a true statement even though you might only survive 5.6% longer. That IS longer.

I have just discovered two great videos with Dr. Michael Greger discussing this very topic. Each video is less than seven minutes and worth every minute of your time. One is called “How Effective is Chemotherapy?” and the other is “How Much Does Chemotherapy Improve Survival?”

Let me be clear. I have no idea what I would do if I had a cancer diagnosis. I have close friends and family members who had advanced cancers and have been treated very successfully and are living active lives years after their treatments.

On the other hand, I have had patients, and, again, close friends and family members who received brutal chemotherapies and died. Many of those seemed to have received no benefit from their treatments and suffered great burdens. Many patients go bankrupt in order to pay for treatments.

Dr. Greger, in the first video says, “A large proportion of cancer patients reported their willingness to declare bankruptcy or sell their homes to pay for treatment. I mean, look, aren’t the high prices justified if new and innovative treatments offer significant benefits to patients? But you may be shocked to find out that many FDA-approved cancer drugs might lack clinical benefit.”

In his second video he referred to a study reported in the Journal of the National Cancer Institute. “In fact, the most expensive drug they looked at, the one costing $169,836 a year, did not improve overall survival at all, and actually worsened quality of life. That’s $169,000 just to make you feel worse with no benefit. Why pay a penny for a treatment that doesn’t actually help?”

I am NOT giving medical advice here. I am encouraging all of us to ask questions of our physicians. If a recommended therapy is said to improve survival, ask, “How much improvement?” Is it just 10 days over six months while suffering uncomfortable side effects? Ask about cost. Would I be willing to spend my financial legacy for those 10 days?

This all reminds me of the importance of our own emotional and spiritual preparation for dying. When “our time” comes we will be ready to die… or be healed. Either way, we’re okay.

________________________________________

Cover Photo by Marcelo Leal on Unsplash

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

Being Sued for SAVING the Life of a Patient

Posted by

“I’ll drag mother down to my car and take her to the emergency room myself,” she told me.

The patient had left verbal and written instructions that she did not want to have life-saving treatments when she was dying. A “No CPR” order was on her chart. Knowing her daughter’s feelings, the old lady chose her son as her power of attorney. She conspicuously omitted any mention of her daughter in the document.

I met this patient, her son, and daughter while I was a nursing home chaplain. By that time, the patient had severe dementia, so healthcare decisions were in the hands of the son. The daughter commented about taking her mom to the emergency room in one of our earlier conversations.

A recent issue of Hospice News featured a story about how healthcare institutions are open to lawsuits if they do not honor a patient’s wishes to refuse life-sustaining treatment. We almost always think it is the right thing to save a life. But there are cases of “wrongful life.” That is, saving a patient’s life who had chosen to let a natural death happen.

As it typically happens, the nursing home patient I ministered to went into a slow downward decline. Even the daughter eventually realized that when her mother’s heart finally stopped, it was time. Thankfully, there was no schlepping the poor old lady into the car.

________________________________________

Chaplain Hank Dunn is the author of Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures and the Patient with a Serious Illness and Light in the Shadows. Together they have sold over 4 million copies. You can purchase his books at hankdunn.com or on Amazon.

Quality of Life Publishing Logo

Quality of Life Publishing Co. is the proud publisher of Hank’s books, as well as other branded educational materials for health care & end-of-life care.

www.QOLpublishing.com

Copyright 2023, Hank Dunn. All rights reserved. Website design by Brian Joseph Studios

Volume Discounts for Branded Book Orders

Minimum quantity for branded books is 100. English and Spanish branded books are sold separately. Click here for more information or contact us with questions.

Black

  • 100 to 249 copies: $4.50 each
  • 250 to 499 copies: $3.25 each
  • 500 to 999 copies: $2.40 each
  • 1000 to 1499 copies: $1.90 each
  • 1500 to 1999 copies: $1.60 each
  • 2000 to 3999 copies: $1.45 each
  • 4000+ copies: $1.25 each

Color

  • 100 to 249 copies: $7.00 each
  • 250 to 499 copies: $4.35 each
  • 500 to 999 copies: $3.10 each
  • 1000 to 1499 copies: $2.15 each
  • 1500 to 1999 copies: $1.80 each
  • 2000 to 3999 copies: $1.55 each
  • 4000+ copies: $1.30 each

Volume Discounts for Unbranded Book Orders

Discounts apply to the total books ordered of all titles. Mix and match to get quantity discounts on unbranded books.

  • 1 to 9 copies: $8.00 each
  • 10 to 24 copies: $5.75 each
  • 25 to 49 copies: $4.50 each
  • 50 to 99 copies: $4.00 each
  • 100 to 249 copies: $3.50 each
  • 250 to 499 copies: $3.00 each
  • 500 to 999 copies: $2.50 each
  • 1000 to 1499 copies: $2.00 each
  • 1500 to 1999 copies: $1.50 each
  • 2000 to 3999 copies: $1.35 each
  • 4000+ copies: $1.20 each