1. SEATBELTS ARE CARCINOGENIC! or The Creation of New Modes of Aging and Dying: Societal Implications James Hallenbeck, MD

2. 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

3. 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

4. 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

5. Top 5 Causes of Death 1900

6. Top 5 Causes of Death 1994

7. Where Do We Die

8. 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

9. 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?

10. Culture of Biomedicine Tensions 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 biomedicine Focus on suffering as object of medicine Inclusion of concept of “life-force” in model Understanding illness as something transcending the individual

11. Suffering and Opportunity 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?

17. 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

18. 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)

19. The Disproportionate Burden on Women 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

20. 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…

21. 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?