A commentary: the role of religion and spirituality at the end of life.

Most people cannot control the exact circumstances of their dying—when they die, where they die, how they die, how people treat them when they are dying, and so forth. They cannot be sure that they will die in “a sanctuary imbued with one’s own order” (Kayser-Jones, 2001, p. 3). This is particularly true in the days ahead as limits on health care expenditures become more and more constraining. The fact is that doctors and nurses will be responsible for more and more patients and have less and less time with each patient. This trend is inevitable when one considers the future costs of financing health care and the changing U.S. population demographics up ahead. Medicare expenditures will double in less than a decade ($220 billion/year in 1998 to more than $415 billion by 2007), even before a cohort of 75 million “baby boomers” reaches age 65 and begins to expand the current 35-million-member elderly population to more than 80 million by midcentury (Smith, Freeland, Heffler, McKusick, & Health Expenditures Projection Team, 1998). Moreover, after 2011, the need for health services will increase astronomically as the aging population grows and life expectancy increases with advances in medicine. Within the first half of this century, the ratio of the number of working persons ages 15–64 to the number of persons older than age 65 will drop from 5:1 in developed countries around the world in 1999 down to 2:1 (United Nations, 1999). This means that instead of five working persons for every one retired person, there will be only two working persons for every one person requiring support. What will our health care look like in the decades ahead? The picture is not a pleasant one (Schneider, 1999). Acute care hospitals will be able to treat only the most severely ill patients (this trend is already occurring) and will come to look like today’s intensive care units. After stabilization, sick patients will quickly be discharged to nursing homes, which will start to resemble acute care hospitals. Waiting lists to get into nursing homes will grow longer and longer, forcing the health care of aged and dying patients back into the community, back into people’s homes—with most of the burden falling not on health care providers, but on family members. Lacking family members or the ability to pay for private care, many aging baby boomers could be forced to spend their last days “on city streets and in parks” (Scheneider, 1999, p. 797). The bottom line is that dying patients will become less and less able to control the circumstances of their dying in the years ahead. I agree with Kayser-Jones (2002) that we health care providers must do everything possible to learn about and train doctors, nurses, and family about how to enable and empower dying patients to control the circumstances of their death. However, we health care providers must also consider the changing health care system ahead and identify internal resources and community resources that could help them achieve a “good death,” regardless of external circumstances over which they have no control.