well for people as they die. More specifically, it is intended to stimulate health professionals and managers, researchers, policymakers, funders of health care, and the public at large to develop more constructive perspectives on dying and death and to improve the practices and policies under their control. To these ends, this report stresses several themes.

  • Too many dying people suffer from pain and other distress that clinicians could prevent or relieve with existing knowledge and therapies.
  • Significant organizational, economic, legal, and educational impediments to good care can be identified and, in varying degrees, remedied.
  • Important gaps in scientific knowledge about the end of life need serious attention from biomedical, social science, and health services researchers.
  • Strengthening accountability for the quality of care at the end of life will require better data and tools for evaluating the outcomes important to patients and families.

Context and Trends

In the United States, death at home in the care of family has been widely superseded by a technological, professional, and institutional process of treatment for the dying. That process—its benefits not with standing—often isolates the final stage of life from the rest of living. Likewise, the mobility of Americans quite literally puts distance between many younger and older family members. Many adults, even in middle age, have not lived with or cared for someone who was dying.

Because Americans, on average, live much longer now than they did at the end of the nineteenth century, a much larger proportion of the population dies at an advanced age. More than 70 percent of those who die each year are age 65 or over, and those who die in old age tend to die of different causes than those who die young. For both younger and older people, the major causes of death and the typical experience of dying differ from 100 years ago. The dying process today tends to be more extended, in part because medical treatments can manage pneumonia, infections, kidney failure, and other immediate causes of death that come in the wake of cancer and other "slow killers."

The field of palliative care is one response to the changing profile of death in the twentieth century. It focuses on the prevention and relief of suffering through the meticulous management of symptoms from the early through the final stages of an illness; it attends closely to the emotional, spiritual, and practical needs of patients and those close to them. Other community, professional, and governmental responses include the development of hospice programs, bereavement support groups, and policies and

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