Remarkable advances in public health, nutrition and medical and surgical care have led to steady increases in the life expectancy of Americans. The average age exceeds 78 years.
In our aging society, more than 2.5 million of us will die each year, some from acute illness and injury, others from malignancies or chronic disease. Some of us will die abruptly. Most of us will die more gradually, sometimes sustained by a variety of life-support systems. All of us hope that we can spend our final days free of pain, conversant with our loved ones and in control of our mental faculties.
Because the issues surrounding care during our final months can be so complex, it is easier to postpone them to another day. Only a minority of adult Americans have completed advance directives that spell out preferences for end-of-life care and name a person to assure that these are honored should our judgment be disabled.
The Institute of Medicine, established by the National Academy of Science, addressed these concerns in its 2014 publication Dying in America (iom.edu/Reports/2014/Dying-in-America). The report highlights current barriers to obtaining desired end-of-life care.
* Poor and disadvantaged people, along with racial and ethnic minorities, lack access to information and resources for care as they approach death.
* We have a mismatch between services that are available and those that are needed when cure or remission of illness is no longer possible. Hospice may be overlooked in discussions dealing with life's final chapter.
* Our care system is fragmented and has perverse financial incentives to deliver more intense care regardless of the setting. Communication among the various specialists caring for a patient may be lacking. Health care providers are mostly trained in acute care settings where death is viewed as an enemy that must be defeated at all costs.
* Our nation lacks sufficient health professionals trained in geriatrics and in comfort or palliative care. Few specialty programs include adequate training in managing dying patients. Providers of acute care hesitate to obtain consultations from hospice, seeing it as a sign of failure.
I would add that families and their elderly or chronically ill loved ones are reluctant to discuss dying and the care that is desired in that process. Children or close friends may not know how to initiate such a conversation. Ideally, this discussion should be undertaken in calmer days before the occurrence of illness or injury.
The Institute of Medicine makes a number of recommendations for improving care in life's final chapter.
* Advance directives should be in place and immediate family and close friends should be aware of their content.
* Educational and treatment facilities must assure that care will be personal throughout the spectrum of illness. Care must address a patient's physical, emotional and spiritual needs. Close family members and caregivers deserve accurate, up-to-date information and emotional support.
* Comprehensive, palliative care must be available whether in hospital, extended care facility or home to relieve pain and suffering and to support family and other caregivers. If the patient is estimated to be in his final six months of life, hospice offers the logical support system.
* Palliative care should be routinely covered by health insurance.
* Training programs should be expanded to address a dire shortage of specialists in geriatrics and palliative care. Medical and nursing schools and post-graduate programs need expanded curricula in these areas.
* A broad educational effort should alert the general public to services that are available for end-of-life care. Religious institutions can highlight end-of-life options. Television stations can deliver public service announcements. All media can promote wider understanding of dying.
In an ideal setting, a person in the final stage of his life will be kept informed of what's happening regarding his care. She will have frequent, in-person assessments that include nutrition, pain control and emotional support. Her spiritual and cultural preferences will be respected. He and his immediate caregivers will have 24/7 access, if needed, to supplemental services such as additional pain control or oxygen. The needs of caregivers will be addressed.
The goal is a sense of peace and thanksgiving at the time when a loved one eases away.
Next week: Personal and family preparation.
Contact Clif Cleaveland at cleaveland1000@comcast.net.