A Hospice Nurse Started Chemo. Then Her Employer Fired Her.

Nick Mulcahy

October 08, 2019

This summer, on June 25, Chrissy Ballard, RN, was lying on the couch at home in Nolensville, Tennessee, not feeling well, having recently finished a round of chemotherapy for her breast cancer.

Ballard had also just done 10 hours of cold-capping to prevent chemo-related hair loss (at –38° F), and in recent weeks gained 20 pounds from steroid therapy. The former college basketball player, now 48, was at a low point with "chemo brain," shortness of breath, joint swelling, limited mobility, and symptoms of diminished liver, heart, and kidney function.

The Ballard family.

Chemotherapy "brings you to what feels like death — that is the goal, to kill an aggressive cancer," she told Medscape Medical News.

Her husband Matt Ballard approached Chrissy after getting off the phone with her boss. He had news: Caris Healthcare, where she was hospice admissions nurse in their Nashville facility, was going to fire her. Two days later on June 27, the hospice company made it official: She was terminated.

"It was very confusing to me — I thought it was a mistake when my husband first told me," she said.

The confusion arose out of her understanding — and embrace — of Caris' The Better Way, a list of 20 promises that employees must fulfill every day, including the commitment "to do what is right."

"What I felt in that moment [of being fired] is: This is not right," Chrissy told Medscape Medical News.

"Something's Gotta Change"

Chrissy Ballard's being fired by Caris Healthcare, first reported by The Tennessean, was not the first time the company has been the subject of critical news stories.

One month before Ballard began employment at Caris in July 2018, the company, which was accused of Medicare fraud by the Department of Justice (DOJ), agreed to pay $8.5 million to settle the allegations.

Caris allegedly certified and admitted patients for hospice care who were ineligible for Medicare's hospice benefit (ie, they were not terminally ill).

The alleged Medicare fraud was driven by "aggressive admissions and census targets set by the company," said the DOJ last year.

When Ballard started work, the problems with federal authorities were behind Caris, a for-profit company with 28 hospices in Georgia, Missouri, South Carolina, Tennessee, and Virginia.

In the early days of Ballard's tenure, the census at the Nashville facility was regularly between 50 and 60 patients. But business was booming and just months after Ballard's arrival, the census rose to around 100 patients, she said. (Caris said the facility has an average census of 75 patients.)

As a hospice admissions nurse, Ballard traveled regionally to meet seriously ill patients and transition them from homes, rehabilitation facilities, and hospitals to the Caris hospice. But she also helped out with direct patient care because of the rising census and a shortage of nurses, she said.

This meant that Ballard, who carried the family's health insurance for three high school- and college-aged daughters and her husband, worked long hours.

She typically clocked 60-plus hours a week and even as many as 80 to 90 hours per week a couple of times over a 4-month period, she said.

Matt Ballard said the work hours were a family worry: "I told her this is insane — something's gotta change."

Sure enough, something did change — but not in a good way.

In March 2019, roughly 8 months after starting at Caris Healthcare, Chrissy Ballard was diagnosed with stage 2, hormone-receptor negative and HER2+ breast cancer.

In "Good Standing" But Terminated

Ballard immediately took a leave of absence using short-term disability benefits (for 12 weeks or 60 days).

Chrissy Ballard undergoing chemotherapy.

Her initial treatment was six cycles of chemotherapy with the TCHP regimen, which features docetaxel (Taxotere, Sanofi), carboplatin, trastuzumab (Herceptin, Genentech and biosimilars), and pertuzumab (Perjeta, Genentech). Each TCHP cycle is 21 days long.

But even before chemotherapy was completed, time ran out on the short-term disability, which was all that Caris offered. That was shocking news to the Ballards, who were unaware of that there was no further disability benefit after 60 days.

Meanwhile, Ballard's treatment was far from over — she had to finish chemotherapy, then undergo surgery, followed by radiation, and complete an extended schedule of targeted therapy. The Ballards anticipated a return to part-time work after Labor Day, at the beginning of September.

Ballard wanted to keep her job, which she loved. "Being a hospice nurse is a sacred calling," she said. "I've held many dying patients alone in a room at 2 AM in the morning. You have to care big to do that job. It's not glamorous, it's unseen."

As part of being fired, Ballard received a termination notice, dated July 1. The official explanation was: "Employee was unable to return to work due to health reasons."

The document also noted: "Employee was in good standing."

The timing of the firing — 1 month short of Chrissy's 1-year anniversary on the job — also allowed Caris to avoid regulations of the Family Medical Leave Act, which go in effect after 1 year of employment.

"Family Medical Leave Act gives you the ability to take time off, which can be unpaid leave, and allows you to go back to a job," explained Michael Foreman, JD, director, Civil Rights Appellate Clinic, Penn State Law, College Park, who is not involved in the case.

Caris has said they did nothing legally wrong and, in a statement, said that Ballard could reapply for her job "if and when she is able to return to work."

The statement also reads: "It is important to note that Caris followed legal and proper steps regarding the employee's departure from the company. Reasonable accommodations were extended. The individual has not sought to be rehired and remains eligible for rehire at Caris, with reasonable work accommodations if needed."

Put It in Writing

Frustrated with Caris, the Ballards in August turned to the Equal Employment Opportunity Commission (EEOC), a federal agency that enforces antidiscrimination laws in the American workplace.

According to the Ballards, the EEOC recommended mediation with Caris, but the hospice company was unresponsive. The EEOC's next step could be to file a lawsuit against Caris, but the agency did not say whether that was planned.

Spokesperson Christine Saah Nazer said the EEOC has successfully pursued lawsuits under the Americans With Disabilities Act (ADA) on behalf of employees with cancer who were fired by employers.

Penn State's Foreman, a former EEOC attorney, explained that a disability is a "physical or mental impairment that substantially limits a major life activity."

Talking about Ballard, he said: "She's being treated for breast cancer, [so] I have no doubt that would be viewed as a disability under the Americans With Disabilities Act."

Legal decisions in ADA cases often hinge on the concept of "reasonable accommodation," which in the Ballard case, might include allowing enough time off for treatment, he speculated.

But Foreman provided a caveat: "Putting a time off request in writing is important."

He explained that employees ideally should put the facts of their case in writing and explicitly say: "I have this condition, and I am requesting reasonable accommodation."

Matt Ballard acknowledged that he and Chrissy did not request time off in writing — a move they now regret, but chalk up to the stress of her diagnosis and treatment.

As this article goes to press, Ballard is finished with surgery and is now undergoing radiation therapy for her breast cancer.

The former hospice nurse credits medical oncologist Julie Means-Powell, MD, of Tennessee Oncology in Nashville, with helping her successfully finish neoadjuvant or presurgery chemotherapy. "She understood the potential impact [of the firing] on my treatment and kept me on a healing path."

Matt hopes that the EEOC proceeds with a lawsuit. "We hope legal action changes the culture of this place. We don't ever want to see another nurse go through this."

Editor's note: This article has been updated to clarify that the type of chemotherapy was neoadjuvant or presurgery.

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