Getting Old and Historical Changes Affecting End-of-Life Care

By Tom Smith, Ph.D.

 

At the turn of the century, in the United States, people did not live very long. On the average, people were lucky if they made it to 50 years. By then end of the century the average life span increased by about 30 years. All this is the result of better hygiene and safety, diet, improved medications and a greater knowledge of the course of disease in all its various manifestations and superior care for those who are dying. There are differences, however, in longevity across different demographic groups.

It is almost common knowledge that women live longer than men by about 7 years (notice who collects the life insurance). In 1996, the United States Bureau of the Census reported that there are five women for every two men over 85 years. White women live linger than Black women by about 6 years and White men live on the average 8 years longer than Black males.

Not only are people living longer, but there are more people under and over 65 years than ever before. Interestingly and not surprising, the population overall is getting older. The baby boomers are now in their 50s and are expected to live quite awhile. The Bureau of Census reported that in 1994 one in every eight persons in the U.S. was 65 or older and by the year 2050 projections are that the older adult population will more than double! Those over 85 are the fastest growing demographic and by 2050 are projected to be almost 25% of the older population and 5% of the general population. People are dying older than ever before: Three fourths of those who die every year are older adults.

As was mentioned above, the causes of death have changed over the years. It used to be that infections like pneumonia and tuberculosis were the leading cause of a rapid death. With advances in treating infectious disease and improvements in hygiene, people are now more likely to die of lifestyle diseases. For example, obesity leading to diabetes, heart disease and stroke; or, environmental diseases like cancer or chronic lung or liver disease. People now linger long before death. Nowadays, a quick death is the result of accident, murder or suicide. Protracted degenerative diseases with late onset now kill us.

It used to be that a person died at home with family. That has changed. Interestingly, most deaths occur in the impersonal sterility of institutions, be it hospitals, rural medical centers, hospices or skilled nursing facilities. More recently the number of people dying at home has increased due to desire and the support of the government for home health and hospice services. Many people would rather die in the comfort and familiar surroundings of home with family and friends near instead of the institution where you die (often alone), the sheet is pulled over the body and it stays in the bed growing cold until somebody wheels it out to the refrigerator or for the undertaker.

Additionally, many deaths are now planned and predictable. Discussions now, more often than not, take place between family members, nurses, doctors and the dying person, if s/he is able, negotiating the timing and administration of potentially lethal painkillers that may hasten death or the opposite: Delay death at any costs with modern life-extending technology. This presents us with a whole new set of moral and ethical problems that must be reviewed by multidisciplinary bioethical teams that were heretofore unnecessary. This very complicated decision-making process has resulted in the development of a body of end-of-life legislation, advanced directives that have “do not resuscitate” (DNR) provisions, the Oregon “Death with Dignity Act”, pained discussions of physician assisted suicide and palliative care that relieves suffering, but hastens death.

The infamous controversies surrounding the death of Karen Ann Quinlan many years ago and the more recent Terri Schiavo case demonstrate the tense public attitudes towards these issues; particularly, as “baby boomers” take care of their aging parents and then have to deal with their own end-of-life processes. More and more we hear people say that “I don’t want to get old … I hope I just drop dead”. This may make the decision process go away, but most will die the lingering death identified above. There is much more to come. These end-of-life moral and ethical considerations will be considered in detail later. In any case, increased psychosocial and hospice care will be needed in the very near future.

References

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.