Discussion of death and dying has been called the last great American taboo.
In recent weeks, however, the subject has drawn attention through a four-part Bill Moyers public television special, "On Our Own Terms," which focused on end-of-life care.
Americans are living longer. The population aged 65 and older is expected to double to nearly 80 million by 2050. Science has worked wonders in terms of extending life, but physicians and other care givers generally have done a poor job of helping people navigate end-of-life decisions.
Surveys show that seven in 10 people say they want to die at home; in fact, three-quarters die in medical institutions, in part because of illogical insurance rules that pay for expensive hospital stays more readily than for home hospice care.
One hopeful sign is that hundreds of local groups have been formed across the nation to push for change. One is the Connecticut Coalition to Improve End-of-Life Care.
Reform should include these elements:
* Medical schools must do a better job of training future physicians in end-of-life care. Most schools offer no courses in care for the dying.
Doctors are trained to save lives, and they usually view death as defeat. Dr. Sherwin B. Nuland of Yale University's medical school says doctors are "biomedical gladiators" who see themselves engaged in "a noble war against death." It is important, he notes, for physicians to recognize the point at which their efforts are futile and only prolong suffering.
* Hospitals need to do more to promote palliative care, also known as comfort care, in cases of terminal illness. Experts say that 95 percent of pain in patients with incurable illnesses can be alleviated, but that nearly half of them die in pain because they are not given sufficient medication.
Many doctors worry that patients will become addicted to painkillers or fear that drugs will kill the patient. In general, those concerns have been exaggerated.
* Hospice-style care either at home or in an institution ought to be greatly expanded. People enter hospices after being told they have less than six months to live. Aggressive treatment is stopped and the emphasis shifts to making patients comfortable and relieving their pain.
People should take the time while healthy to talk with family members about their wishes in end-of-life situations and then prepare an advance directive.
There are two types of directives. A living will allows people to put in writing their wishes about medical treatment in the event they cannot communicate. Patients can make it clear, for example, that they don't want doctors to resuscitate them or use feeding tubes to keep them alive.
The second type, medical power of attorney, allows people to appoint someone they trust to make medical decisions for them. The legal forms for each state are available on the Web at www.choices.org.
Too many people spend their final days alone in hospitals connected to expensive machines and often needlessly in pain.
However, the emerging national debate on end-of-life issues offers hope that a more enlightened system is possible.