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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

Support for this project was provided by the Project on Death in America of the Open Society Institute, the Greenwall Foundation, the Health Care Financing Administration, the Culpeper Foundation, and the Robert Wood Johnson Foundation. Additional support was provided by the Commonwealth Fund, the Archstone Foundation, and the Irvine Health Foundation. The views presented are those of the Institute of Medicine Committee on Care at the End of Life and are not necessarily those of the funding organizations.

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Library of Congress Cataloging-in-Publication Data

Approaching death : improving care at the end of life / Committee on Care at the End of Life, Division of Health Care Services, Institute of Medicine ; Marilyn J. Field and Christine K. Cassel, editors.

p. cm.

Includes bibliographical references (p. ) and index.

ISBN 0-309-06372-8 (cloth)

1. Terminal care—United States. I. Field, Marilyn J. (Marilyn Jane) II. Cassel, Christine K. III. Institute of Medicine (U.S.). Committee on Care at the End of Life.

R726.8.A68 1997

362.1′75′0973—dc21 97-21175

Copyright 1997 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Front cover: Original photograph by Charlotte Hebeler; design and photo manipulation by Francesca Moghari.



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