As a doctor at a cancer hospital, I'm often asked about death—not
the spiritual side of it, but the practical. Specifically, people ask
me if it is better to die in a hospital or at home. Until recently I
had always voted for death at home, given its promise of relative
serenity. I still think it's better. But a friend's recent experience
with his elderly father reminded me that hospitals, despite their noise
and hurry, still do a few things well in those difficult last moments.
my good friend's father died at home, it was as orderly and calm as
could be hoped for. Yet what was unanticipated was the chaos that
followed soon thereafter, an odd mix of sober adult heartbreak and the
darkly comic. How did the expected death of a nonagenarian result in
such commotion? Because few anticipate the bureaucratic adventure that
ensues after a death at home. Hospitals and hospices, with their
legendary capacity for completing forms, handle the task with chilly
efficiency. But without their administrative help, doing it yourself
isn't so easy.
Long gone are the days of the cowboy
gently closing his slain buddy's eyes and moving on. When someone dies
at home, a licensed professional must determine that the person is
indeed dead. This should be worked out in advance with the doctor, but
we have a way of disappearing at crucial moments. If this happens, the
only option is to do what my friend did and call an ambulance—for a
dead person. There are other annoyances: the death certificate must be
completed in black ink (using only certain approved diagnoses), an
undertaker needs to be selected, and law enforcement must be called to
establish that no foul play occurred. As happened with my friend,
officers may arrive ready for trouble—suspects, motives—and meet only a
the cost of health care without cutting its quality is the central
issue in the reform debate. Since a large proportion of Medicare
dollars are spent on patients in the last months of life, savings could
come from facilitating the wishes of those who choose to die at home.
This is best accomplished with the active support of hospice care
rather than the (well-intentioned) path my friend took. This approach
would be less expensive than admitting a loved one to a hospital—and
would assure tranquility for the person dying and dignity for the
family that remains.
Sepkowitz is an infectious-disease specialist at Memorial Sloan-Kettering Cancer Center in New York City.