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Death no longer comes quickly to the seriously ill. Even as health and life spans improve, people also live longer with the debilitating diseases that eventually take their lives. "For the first time in human history, we can anticipate our mortality," says Stephen P. Kiernan in Last Rights: Rescuing the End of Life from the Medical System (St. Martin's). "We can watch its slow approach."

When both Tony Snow and Elizabeth Edwards announced at the end of March that they had been diagnosed with a recurrence of cancer, pundits analyzed the potential political repercussions. They discussed each patient's diagnosis and expected survival time. They praised each for their courage and for bringing greater public awareness to their diseases.

Snow and Edwards say they will resume their regular activities as soon as possible. Thanks to modern medicine, they likely face years of productive living. But cancer will always loom in the background. For Edwards, it is incurable. And for Snow, the average survival time for people whose colon cancer has spread is a little more than two years.

But a fact larger than any political repercussions remains largely unsaid: This is what dying is like now in America.

Edwards and Snow are young and widely known, making their cases somewhat different than the average cancer patient whose illness is terminal. But like the rest, they face a future measured in short months and years. One study found that most deceased patients had been sick three years with the illness that eventually took their lives.

As medicine has become increasingly effective at overcoming certain diseases, Kiernan says, the leading killers are now gradual ones. For example: "Despite decades of research, cancer fatalities in the past thirty years have increased 22 percent," writes Kiernan, a newspaper reporter. "We used to die primarily of heart attacks, strokes, and accidents. Now we die mostly of cancer, Alzheimer's, and aids."

"That shift," Kiernan says, "presents an opportunity for sublime end-of-life experiences—last wishes fulfilled, pain managed, relationships repaired, spiritual calm attained—which almost everyone misses."

We miss those sublime experiences because we expect, and our medical technologies are prepared for, emergencies. The nation's leading killer for much of the past century was heart disease, Kiernan notes. Strokes and accidents have also been major causes of death. So our hospitals are prepared to almost literally bring back the dead. Our money, our resources, our doctors' training, and our expectations (thanks to hospital dramas) are geared to heroically saving lives.

Yet the new, more gradual way we die "has gone unremarked upon and comes as a tragic surprise for millions of Americans every year. Indeed, the seismic shift in dying has altered neither public policy nor individuals' behavior."

Kiernan invests most of his words outlining the problems caused by a medical system poised for emergencies (for which it is phenomenally capable) in an era of gradual dying, from Medicare policy to hospital profits to conflicts between doctors and families. Those who pay the price are families and patients. "The temptation to deploy an arsenal of medical armaments could easily lead to the kind of dying few people would choose—in intensive care, sustained by machinery, at huge expense, and with little personalized treatment."

Because our medical institutions are well prepared to deploy this arsenal, significant resistance from families is required to avoid it. This despite the fact that 90 percent of Americans say they don't want to die in the hospital attached to an array of machines.

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September 2007, Vol. 51, No. 9