By Elizabeth Luth

PhD student, Sociology, Rutgers University 

When
asked, the majority of
Americans say they would like to die at home, free from
pain, and having said goodbye to loved ones. Dying peacefully at home and
surrounded by loved ones may not seem like a lofty aspiration for the end of
one’s life.

Yet,
the reality of death in America often does not reflect those expectations. Despite
declines in the proportion
of Americans dying in hospitals, Americans spend more time than ever before in
intensive care units in the months leading up to death, often undergoing
invasive and painful procedures that add days to one’s life while compromising
quality of life.

Washington on his Deathbed Oil on canvas painting by Junius Brutus Stearns, 1851, Dayton Art Institute

Source: http://commons.wikimedia.org/wiki/File:Life_of_George_Washington,_Deathbed.jpg

At
first blush, it may seem like where and how we die is a matter of intimate personal
preference or choice (called agency in
sociological parlance). However, these decisions are not a matter of choice
alone. Social structure
is also at play. As Max Weber
explains, institutions and the bureaucracies they embody organize people and
assign roles and responsibilities so that society runs smoothly. The flip side
of this organizational facilitation is that, in order to consolidate and
maintain their authority, institutional structures impose constraints on
individuals. 

The
institution of medicine—doctors, hospitals, and the professional authority they
embody—is inextricably intertwined with death and dying. Doctors and hospitals
are important facilitators and barriers to achieving a “good death.” Physicians
have the authority to recommend specific treatment or determine whether a
patient should receive hospice care. Hospital policies and procedures also dictate
the type of care patients automatically receive in an emergency or are offered
for chronic illness.

Indeed,
much medical sociological work has been devoted to this topic in the last
half-century, addressing topics ranging from how patients
are categorized and treated upon arrival
to the emergency room to how
doctors and hospitals approach
death and
dying. 

However,
if we stop there, we miss a major part of the sociological story. In addition
to considering the complicated structural relationship between medicine and
death, we need to also think about how personal experiences with and everyday
images of illness and death inform the disconnect between how people say they
would like to die and what they are likely to experience.

Personal
experiences with death are related to social demography and socialization. From
a population perspective, due to increased life expectancy, most people in the
United States die at increasingly older ages. Rather than experiencing death
for the first time during childhood and then multiple times throughout the
course of our lives, many of us will not face the death of a close loved
one—such as a parent, sibling, or spouse—until pretty far into adulthood. 

It
is a good thing that people are living longer. However, because we are often not
directly exposed to death until our 40s, 50s, or 60s, and therefore not
socialized to accept it as a normal part of life, the experience of death is unfamiliar—to
say the least—and particularly jarring.

In
addition to socialization factors, the images of illness and death presented in
popular media also reflect and shape how we experience death as a society. While
we may not personally experience the death of a loved one first hand for the
first two-thirds of our lives, we are continuously—almost daily—exposed to
death through popular media. The images of death presented in the media reflect
an interesting—and confusing—contradiction in our collective understanding of
death: a simultaneous denial of and fascination with death. 

Television
medical dramas such as ER and House provide an example of both
fascination with and denial of death. The genre’s formula necessitates that
every episode be structured around a life-threatening experience-we are drawn
in and kept engaged by the idea that the patient on our television screen could
die at any moment. At the same time, patients on these shows rarely do actually
die. A study of medical dramas
indicated that about 75% of patients survived hospital resuscitation (CPR). The
actual CPR survival rate is estimated to be
closer to 8%. If our only exposure to CPR is by watching George Clooney or Hugh
Laurie save someone from the brink of death (and I would venture to say that is
accurate for a good number of people), we may have some unrealistically high
expectations for CPR’s ability to save us from death.

Similarly,
news coverage of death sensationalizes death, rarely referring to the
uncertain, human, or even mundane aspects of dying. Death is often depicted as
the result of tragedy (such as the recent fertilizer plan explosion in West, Texas) or terror. Alternatively,
death is something that happens in distant places as the result of natural
disaster or war. Even when death does come to individuals that are chronologically near the end of life, it is characterized by the
media as something to be unquestionably avoided (for example, when an 87-year-old woman dies of a stroke ).

Few of us can say with absolute confidence
what our futures hold, the extent to which our aspirations will become reality,
how similar or different our lives will be from those around us. We can,
however, be completely sure that we will have one shared experience: death. And
yet, as a society, we seem largely unconcerned with the reality of how death
occurs on a day-to-day basis. Instead, we unquestioningly consume sensational
accounts of death as either heroically averted or tragically and unfairly
endured. In doing so, we almost guarantee that the disconnect between how we
hope to spend our final days and moments and how we are likely to do so, will
remain.