seatbelts are carcinogenic! or the creation of new modes of aging and dying: societal implications...
TRANSCRIPT
SEATBELTS ARE CARCINOGENIC!
or
The Creation of New Modes of Aging and Dying:
Societal Implications
James Hallenbeck, MD
Topics of Discussion
• How we have created new modes of aging and dying
• Trying to fill the cultural gap of modern dying
• A look to the future…• System implications • Personal Implications• Gender-related issues
Key arguments
• We are still mortal• All probabilities must add up to 100%
– Eliminating one cause of death increases the probability of other causes
• How we die has changed radically• Dying as a cultural activity is conservative• A cultural gap in how we die has been created• We are headed toward a major crisis
Changes in How We Die
• Most deaths now in institutions– Families less able to care for dying patients
• Most deaths due to chronic illness• Dying usually takes a long time• Dying is expensive• Many options available
– Treatments, care systems, where to die
Many now view dying itself as a choice
Top 5 Causes of Death 1900
Rank Cause of Death Percentage
1 Influenza,Pneumonia
11.8
2 Tuberculosis 11.3
3 Gastritis,Enteritis
8.3
4 Heart Disease 8.0
5 Stroke 6.2
Top 5 Causes of Death 1994
Rank Cause of Death Percentage
1 Heart Disease 32.1
2 Cancer 23.5
3 Stroke 6.8
4 COPD 4.5
5 Accidents 3.9
Where Do We Die
60%20%
20%
OtherNursing HomeHospital
Care for the Dying Is Expensive
• 2.3 million Americans die annually
• Expense of care for the dying: 45 billion/year for last six months of life– 7.5% of healthcare expenditures for 0.9% of
population
• Dying is largely publicly funded– However 30% of families impoverished by
private expenditures for dying
Dying Takes a Long Time
• From brief transition period to LIFE STAGE
• Social Implications – new systems needed• Cultural Implications – meaning of stage
and relation to other life stages• Personal Implications- what is to be
accomplished in dying?
When does dying begin?
Culture of BiomedicineTensions
• Individualism– Autonomy
– Disease in the individual
– Consumerism
• Egalitarianism – Health care as a right
• Mechanistic/technologic – Reductionist
– Paternalistic
– Bureaucratic
• Capitalism– Health care as commodity
Lacking in modern biomedicineFocus on suffering as object of medicine
Inclusion of concept of “life-force” in modelUnderstanding illness as something transcending the individual
Suffering andOpportunity
• New forms of suffering – Pain and other symptoms– Economic hardship– Loss of control– Existential and Spiritual
What new opportunities for growth and transcendence arise from such suffering?
Predictions
• Health care expenditures as % GDP will continue to grow
• Ratio of Elders in need of care / Available Caregivers will grow dramatically
• Continuing shift in locus of care for chronically ill patients out of hospital and into the community
Implications if Prediction Accurate
• “De-medicalization” of chronic illness and dying• A further shift in care burden to families and
communities unprepared and unable to accept such a burden
• A caregiver crisis– Families unable to provide care
– Inadequate number of professional caregivers (poor, minorities and immigrants)
The Disproportionate Burden onWomen
• Women much more likely to be caregivers– of husbands– of parents and parents-in-law: often while
employed and raising children
• Women less likely to have caregivers– As more likely to survive spouse– Men less willing to take-on caregiving roles
Something Has to Give
• Reconstitution of nuclear families, traditional roles (unlikely)
• Massive caregiver immigration (possible) • Legalization and sanctioning of assisted
suicide (likely)• A new wave of institutionalization (very
likely)
Possibilities…
Moral(s) of the Story
• Dying at home will continue to be the exception, not the rule and a privilege of the rich
• National health care initiatives are unlikely to ‘save us’
• We must take both personal and community responsibility for how we will age and die
Can we create new institutions to meet our changing needs?