on the sensational, violent, or sentimental and which often depict death as an event without much social or personal context.

This chapter provides a brief epidemiological profile of dying and death in the United States, an overview of research on attitudes toward dying and death, and a short concluding reflection on cultural characteristics that influence attitudes and practices related to the end of life. Although the shifts in the rates and causes of death over time are, in considerable measure, the result of nonmedical factors such as better public health measures and economic development, they also reflect—and, in turn, shape—the technological capacities and organizational characteristics of health care including its continued emphasis on acute rather than chronic illnesses. Understanding when, why, where, and how people die and what they think about death and dying can help policymakers ask better questions about whether health care and supportive services are appropriately organized and distributed to fit the needs of dying patients and their families.

The discussion below shows that Americans, on average, live much longer now than they did at the end of the nineteenth century and that death in infancy has moved from routine to rare. Those who die in old age tend to die of different causes than those who die young, and 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 control pneumonia, kidney failure, and other immediate causes of death that accompany cancer, heart disease, and other "slow killers." Because death from these conditions can often be postponed, questions about life-prolonging treatment become central issues for patients, families, and clinicians. In the process, the tasks of preparing for death and caring well for those who are dying can be neglected, and opportunities for spiritual growth or completion of important relationships can be missed.

By arguing for changes in attitudes and practices related to dying and death, the committee does not endorse a romantic view of the past. In earlier ages, familiarity with death did not necessarily translate into kind treatment of the dying, particularly for those marked by disfiguring conditions. Likewise, familiarity did not banish fear, shame, or other difficult emotions in the face of death.

When People Die: The Aging of America

Although less than 1 percent of Americans will die this year, the total number of deaths will be well over 2 million. In 1995, estimated deaths in the United States were 2,312,180 (Rosenberg et al., 1996), up from 1,989,841 in 1980 (NCHS, 1985) and 2,148,463 in 1990 (NCHS, 1994). To put this number in some perspective, 1995 estimated births in the United



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