Aging and Death in the Modern World

The size of the elderly population in the United States has grown tremendously since 1900. As baby boomers who were raised with better nutrition and vaccination, grow older in an era of ever improving health care, the sheer numbers of aged continue to increase at an unprecedented rate. This has led to a change in the leading causes of death in the United States, with a shift from infectious diseases, to chronic diseases.

This shift in cause of death has led to a transformation in how death occurs in the United States. Previously the majority of elders spent the end of their lives at home where they had a relatively quick death, but now death typically occurs after an extensive illness that requires expensive long-term care, that is provided by a nursing home or other skilled care facility.

These population and medical transformations have also led to a change in the aging and dying process. In previous centuries, aged persons remained living at home with family members, died in their homes, and were laid out in their homes, with the entire family taking part in the preparation of the body, the wake, and sitting over the body before the funeral. But in the past century there has been an increasing medicalization of dying, and now elders spend their final days living in institutions or living alone, their deaths occurring in an institution, and preparation of the body is taken care of by the funeral industry.

This shift has implications for both families and the community, as death has shifted from a natural event experienced on a regular basis, to an occurrence experienced only in a hospital or a funeral parlor. Additionally, funerals are no longer attended by the community at large, but are instead attended only by close family and friends, which may serve to remove the support system for bereaved families. Death has become an alarming stranger.

As we treat those who are aged and dying now, so shall we be treated by succeeding generations when we ourselves become old. This should give us pause for reflection, as parents and grandparents who wish to age and die in their own homes, instead spend the end of their lives in institutions. Just as aged individuals shape the expectations of aging, so does our treatment of aging individuals shape the expectations of how the aged will be treated in the future.

When asked how they would prefer to die, no one ever answers that they would like their death to occur attached to wires and tubes, with constant pain, surrounded by the impersonal sights and sounds of the modern hospital. Although people would prefer to die at home, in their own beds, surrounded by their loved ones, this ideal has become rare in modern American society, as aging and death have become increasingly medicalized.

It is possible that our fear of death is due in part to this medicalization, and with the profusion of strange tubes and monitors that place the sick or dying patient at arm’s length. The very machinery of medicalized death places the witnesses of that death at a distance from the patient. Someone so wound up in machinery does not seem approachable, huggable, or touchable. Children, who are now more likely than ever before to know their grandparents, are frequently kept away from dying elders, and away from funerals and wakes.

This is not to say that we are not well served by many of the improvements in the medical system, or that we should accept all death and disease without a fight. There are cases where death should be fought with all the medical technology available, but we may be better served by accepting death as a natural and inevitable part of life for the oldest old, who have come to accept their death as expected and perhaps even welcome.

The institutionalization and medicalization of death do have benefits, which include better awareness of the pain that is suffered by many dying elders, which brings the realization that pain in the aged dying patient can and should be treated aggressively. This makes death easier for not just the elders, but for the family and friends who may gather to spend the time with the dying elder at the end. Part of the reason children may be kept away from the bedside of a dying elder is because seeing someone in pain can be a disturbing experience, especially for a child. If the pain of the dying person can be kept at bay, this may make it easier for children to spend more time with dying grandparents, aunts, and uncles, which in turn may make the process of dying less frightening.

Medical advances can also allow life to be extended long enough to give family members time to arrive from across the country. This means that distant family members can arrive in time make their farewells, and it may help reduce instances of regret where someone wishes they had had the chance to resolve past problems, say I love you, or just say goodbye.

Medicine is making advances in the treatment of many illnesses, as well as in the field of pain management, and some of those advances should allow the treatment of aged and terminally ill patients to occur in the home instead of in an institution. This could allow elders, if they have the social support, to spend their final days at home with their families instead of in a hospital or care facility.

Increased demand upon the health care system from a growing population of elders, and a growing understanding that death does not—and should not—have to occur with pain and loneliness, creates a health care system with immense requirements to meet. The care that should be the right of every elderly patient requires far more skilled personnel than the health care system currently has, and the projected population increases will only exacerbate this problem. This will place a strain not just on medical institutions, but upon families who may have to struggle to provide care for their loved ones, and businesses and employers who will have to adjust to the needs of the care-taking adults.

The Family and Medical Leave Act provides workers with  the legal right to take leave to care for a sick or dying relative. Although an employee may have a legal right to do so, the social support to actually do so may not exist in many workplaces, and workers may also be subtly discouraged from taking advantage of such policies.

One thing that can be done to alleviate some of the problems associated with dying is to educate doctors about pain management, the physical symptoms of death and dying, and how those symptoms should be treated. The fear of future pain may be a source of suffering for some patients, and addressing this fear is a necessary component of palliative care. A study of Physician Assisted Suicide in Oregon found that not all patients who received a prescription for a lethal dose of medication used it, suggesting that for some patients the knowledge that they could end their life if the pain became too much was enough to reduce their suffering. Knowing and understanding these aspects of end of life care are important both for reducing the suffering of the individual who is dying, and for the family members who will witness the death.

Doctors also need to be trained in how to educate patients and families about the issues of hospice, palliative care, and end of life care. A doctor needs to be aware not just of the concept of events that may occur at the end of life, such as anorexia, terminal dehydration, terminal sedation, and the double effect, the doctor must also be able to explain those issues to patients and their families. Knowledge that a patient can be sedated until death to relieve pain and suffering does no good if the doctor does not to explain that idea to the patient and their family. If a doctor is not comfortable discussing these issues with patients and their families, how can patients and families feel comfortable coming to the doctor with their concerns and issues?

Whether these medical advances and treatments will allow for a shift of place of death back to the home instead of in a hospital or institution remains to be seen. The technology is advancing rapidly enough that most seniors who would like to die in their homes should be able to do so, but whether family members and caregivers will agree to this is yet unknown. It is also possible that the changes occurring as a result of the graying of the baby boomer generation may place greater power in the hands of the aged, and may help to shift the place of death from the hospital back into the home.