jority of patients in both Gallup surveys expressed interest in a comprehensive program of end-of-life care at home, not all of those who were interested identified the term "hospice" with such a program. In the 1996 survey, 70 percent of respondents reported that they would seek hospice care, and 62 percent said they would still seek curative care. The latter figure indicates that people do not necessarily wish to forego curative efforts when they accept comprehensive palliative care.

Other research suggests that younger people express more willingness to forego resuscitation or ventilator support than do older people when they are asked hypothetical questions about preferences in the event of terminal illness (Gallup and Newport, 1991). A small study of patients seen at a Veterans Affairs medical center found that almost half said they would accept intubation and ventilator support even if the outcome would be persistent mental deficits (Mazur and Merz, 1996). In one exploratory study investigating patient views of states worse than death, coma, severe dementia, and loss of such functions as the ability to feed oneself were cited as possibly worse than death, but the stability of such views is unknown (Pearlman et al., 1993).

Surveys tend to highlight "mainstream" attitudes, or at least those attitudes easily tapped by pollsters, but there really is no "one" American attitude toward death and dying (Koenig and Gates-Williams, 1995; see also Appendix D). For example, studies of attitudes about advance directives and preferences for end-of-life care tend to show that whites are more favorably inclined to advance directives than African Americans and more likely to indicate that they would forego life-sustaining therapy (Caralis et al., 1993; Garrett et al., 1993; Steinberg et al., 1996). In a study of cancer patients (not necessarily terminally ill), researchers found cultural differences in views on family roles, information disclosure, expression of pain, and attitudes toward illness (Die Trill and Holland, 1993). In a study of 800 elderly patients, the University of Southern California found that the family dynamics in immigrant Korean or Mexican families allowed for less patient autonomy than in black or white families that had not recently immigrated (Blackhall et al., 1995; see also Mydans, 1995). The immigrant families were far more likely to believe that the truth about terminal diagnoses should be withheld from patients. Families, and not patients, were considered the proper decisionmakers in end-of-life care.


Dying is a both a biological process and a psychological and social experience that occurs in a cultural context. Trying to characterize briefly the distinctive aspects of the dominant American culture that influence attitudes toward death and dying is a task fraught with the risk of oversim-

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