In 1900, the average lifespan was 47.3 years; by 1997 it had increased to 76.5 years, a gain of 29.2 years in less than a century (Kramarow, Lentzner, Rooks, Weeks, & Saydah, 1999). This overall gain in length of life obscures important differences in longevity across demographic groups. For example, women currently live seven years longer than men do. Among those 85 and older, there are five women for every two men (Bureau of the Census, 1996). An African American woman can expect to live 74 years, compared to 80 years for a European American woman. The estimated life expectancy at birth for African American men is 65 years, as compared to 73 for European Americans (Field & Cassel, 1997). Social class factors, including income and education levels, also affect longevity.

The age distribution of the population in the United States has changed substantially in this century. The number of persons under age 65 has tripled in this period of time while the number of persons 65 or over has jumped by a factor of 11 (Bureau of the Census, 1996). It is particularly noteworthy that the rate of aging of the population is expected to accelerate for the next half century. In 1994, one in every eight persons in the United States was over 65. By the year 2050, the older adult population is expected to more than double, resulting in a ratio of one older adult to five younger persons. The "old-old," those 85 and over, are the most rapidly growing sector of the aged. By the year 2050, people over 85 are expected to make up 24% of older persons and 5% of the entire population in the United States, numbering over 19 million. Today, three-fourths of those who die annually are older adults. Assuming continued increases in longevity, the proportion of those who die past age 75 will also increase (Field & Cassel, 1997).

The causes of death have also changed dramatically. In 1900, the ten leading causes of death were pneumonia, tuberculosis, diarrhea and enteritis, heart disease, stroke, liver disease, injuries, cancer, senility, and diphtheria (Centers for Disease Control and Prevention, 1999). Most people died from infectious illnesses that caused death with certainty and relative rapidity. By 1998, the ten leading causes were heart disease, cancer, stroke, chronic lung disease, pneumonia and influenza, accidents, diabetes, suicide, kidney disease, and chronic liver disease (Martin, Smith, Mathews, & Ventura, 1999). Thus, the contemporary list includes only two causes of death (accidents and suicide) that lead to a quick death. It has been estimated that 70-80% of people in advanced industrial nations now face death later in life from chronic or degenerative diseases characterized by late, slow onset and extended decline (Battin, 1996).

The location where death typically occurs has also changed, moving from the home to technologically sophisticated and often impersonal settings. It has been estimated that in the United States nearly 60 percent of all deaths occur in hospitals or medical centers. Another 16 percent occur in other institutions, such as nursing homes or hospices (Benoliel & Degner, 1995). Only a minority of people die in the care of formal hospice programs, and the majority of these hospice deaths involve cancer diagnoses. More recently, the proportion of those who die at home has begun to increase because changes in Medicare benefits have led to increased availability of home hospice services (Field & Cassel, 1997).

The timing of an individual's death has also changed. As the dying process and death have moved from taking place at home to medical settings, professionals have exerted more control over the timing of dying. Technology now permits life to be greatly extended. It appears that in a growing number of terminal cases medical decisions are made to withhold or withdraw treatment (Field & Cassel, 1997).. In 1992, it was estimated that 70 percent of the 6,000 deaths that occur daily in the United States are somehow timed or negotiated with family, doctors, and the dying person when competent, quietly agreeing to not use death-delaying technology (In re L.W., 1992).

Scientific advances in medicine have produced an expanded array of interventions that present individuals, families, and health care professionals with an increased number of very difficult decisions about the timing and course of the dying process. This change has resulted in an expanded role for bioethical review teams in many clinical settings. In 1983, one percent of all medical facilities in the United States had ethics committees and/or multidisciplinary teams that served to oversee difficult medical decisions. By 1993, the American Hospital Association estimated that 60-85% of hospitals had ethics committees (Webb, 1997).

The life-extending potential of medical interventions has also led to the development of a whole new body of end-of-life laws. All 50 states have addressed end-of-life issues either by legalizing some form of advance directive or by enacting alternative provisions for end-of-life decisions in the form of family consent, surrogacy, or succession laws that do not require a document to be signed prior to loss of competence. Although it is beyond the scope of this report to detail all of the changes in end-of-life legislation, three recent legal developments are worth noting because they have widespread significance for end-of-life care and they continue to be the focus of high-profile debates in both politics and the press. One is The Oregon Death with Dignity Act, which was first implemented in 1997 and permits physician-assisted suicide under limited, carefully specified conditions. The second one are the rulings of the U.S. Supreme Court, in June of 1997, that there is no constitutional right to physician-assisted suicide and that states are free to decide whether they wish to legalize this practice (Vacco v. Quill, 1997; Washington v. Glucksberg, 1997). The last one is The Pain Relief Promotion Act, introduced in the United States Congress in 1999. If enacted, funding for training in palliative care would be provided but physicians would be in violation of the Federal Controlled Substances Act if they prescribed or administered opioids, barbiturates, or other controlled medications with the purpose of helping a person to die. Thus, passage of The Pain Relief Promotion Act would functionally negate the Oregon law and prohibit other states from enacting similar laws.

Changes in public attitudes about participation in medical decision-making and about seeking help from mental health professionals are likely to produce corresponding changes in expectations about end-of-life care. In the past two decades, there has been an increased demand by individuals and families for active participation in medical decision-making, especially among well-educated and middle class populations. With the coming of age of the baby boom generation, larger numbers of people in the United States have come to accept mental health services as an important resource for dealing with difficult decisions and emotionally challenging situations. These shifts in attitude, combined with the fact that the baby boom generation is increasingly dealing with end-of-life care for their parents and the prospect of their own mortality, suggest the likelihood of an increasingly sophisticated demand for psychosocial services in dealing with end-of-life decisions.

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References

Battin, M. P. (1996). The death debate: Ethical issues in suicide (pp. 175-203). Upper Saddle River, NJ: Prentice-Hall.

Benoliel, J .Q. & Degner, L. F. (1995). Institutional dying: A convergence of cultural values, technology, and social organization. In H. Wass & R. A. Neimeyer (Eds.) Dying: Facing the facts (pp. 117-141). Washington, DC: Taylor and Francis.

Bureau of the Census, U.S. Department of Commerce, Economics and Statistics Administration (1996). Sixty-five plus in the United States. (Current population reports, special studies, 23-100). Washington, DC: U.S. Government Printing Office.

Centers for Disease Control and Prevention (1999, July 30). Control of infectious diseases. Morbidity and Mortality Weekly Report, 48(29), 621-629.

Field, M. J., & Cassel, C. K. (Eds.). (1997). Approaching death: Improving care at the end-of-life. Washington, DC: National Academy Press.

In re L.W., 482.N.W.2d 60 (Wis. 1992).

Kramarow, E., Lentzner, H., Rooks, R., Weeks, J., & Saydah, S. (1999). Health, United States, 1999 with health and aging chartbook. Hyattsville, MD: National Center for Health Statistics.

Martin, J. A., Smith, B. L., Matthews, T. J., & Ventura, S. J. (1999). Births and deaths: Preliminary data for 1998. National Vital Statistic Reports, 47(25), 1-48.

Vacco v. Quill, 117 S.Ct. 2293 (1997).

Webb, M. (1997). The good death: The new American search to reshape the end of life. New York: Bantam.

Washington v. Glucksberg, 117 S.Ct. 2258 (1997).

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