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This month Congress will consider ways to increase the use of Medicare's hospice benefit. Senator Charles Grassley, the Republican who chairs the Special Committee on Aging, wants to clarify Medicare's requirement of a six-month life expectancy as a guideline, not a hard rule. (Reformers hope Congress will formally declare it an average instead of a cap.) Senators Susan Collins, a Republican, and Jay Rockefeller, a Democrat, also plan to introduce a more general end-of-life health-insurance plan.
Next, more states could begin programs like one in Oregon that offers all patients a form stating their preferences on resuscitation, tube feedings and so on. That state has also benefited from two referendum campaigns on assisted suicide, which taught voters a great deal about the current shortcomings of end-of-life care. Today only about a third of Oregon residents die in institutions, in contrast to the 75% national average. As a state, Oregon spends the lowest amount on inpatient care in the final six months of life.
Cities can adopt some of the changes under way in Missoula, Mont., where a project called the Quality of Life's End is educating local doctors, lawyers, clergy members and students about what it means to die well. For example, both of Missoula's hospitals now treat pain as a fifth vital sign, ensuring that medical staff will take it seriously. Recently the project contacted Missoula's lawyers to begin teaching them to write better advance directives. And project volunteer Gary Stein incorporates end-of-life issues into the high school psychology course he teaches.
Graduate schools could also teach more about how we die, particularly medical and nursing schools as well as seminaries. Current managers of nursing homes and geriatric wards could inquire about the A.M.A.'s course on end-of-life care and subscribe to the three-year-old Journal of Palliative Medicine. They can learn a lot from Veterans Affairs hospitals, many of which have made improvements in end-of-life treatment in the past five years.
Doctors could speak more openly with patients about prognosis and mention comfort care when a serious illness is first diagnosed--even as traditional treatments are explored. Then, if a cure isn't found, advises Dr. Fred Meyers, who chairs the department of internal medicine at the University of California at Davis, "be honest and say, 'I don't think I can cure you, but I'm not going to abandon you; you're going to get good consultation, we'll take care of your symptoms and take care of your family.'"
The most challenging reform may be to get patients to become their own advocates for better death. That would require frank talk about a somber subject. That's not an entirely unreasonable expectation, reformers contend. They point out that Americans successfully changed birth in the 1960s and '70s by getting fathers more involved and focusing more on mothers' well-being. Byock believes that the boomers, who demanded many of the changes in the way we come into the world, will be equally insistent on changing the way we leave. "The baby boomers are the most self-centered, arrogant, willing-to-try-new-things generation ever," says the 49-year-old, who drives a Saab. "They're going to bring the same collective raising of expectations to the care we give people who are living through the end of their lives."