- The Inevitable Hour: A History of Caring for Dying Patients in America by Emily K. Abel
death, hospitals, hospice
While many Americans in the nineteenth century accepted death as a common and inevitable part of life, the experience and meaning of dying changed between 1880 and 1965 as the growing prestige of medicine led both patients and doctors to reject the inevitability of death and to emphasize the fight for recovery instead. As Emily K. Abel argues in her new book, the most significant consequence of this focus on cure was the shunning of dying patients, whose existence threatened the progressive image of American medicine that emerged after the bacteriological turn in the late nineteenth century. Although medicine could not completely ignore the dying, physicians and patients increasingly sought new medications and technologies to avert death. It was not until the 1960s that critics succeeded in challenging the standard treatment of terminal patients and advocated for more dignity for the dying. Abel’s narrative provides the history and context leading up to these challenges. [End Page 347]
Abel’s narrative undermines several prevailing assumptions about the treatment of terminal patients in twentieth-century America. Sociological critics of American hospitals have claimed that physicians sought jurisdiction over the dying and have blamed the development of life-extending technologies at midcentury for dehumanizing death in the hospital. Abel convincingly proves that the economic and educational needs of the hospital actually led to policies that excluded the dying. While she agrees that dying in the hospital often was an undignified experience, she demonstrates that this was not a result of technological advances but was instead characteristic of American hospitals from their earliest years. Furthermore, the development of alternative care facilities did not replace familial care for the dying, and many Americans continued to die at home well into the twentieth century. Finally, Abel claims that the cultural authority of medicine did not lead all patients to eschew their spiritual faith for the promises of medical science, thus arguing against a broad historical narrative of secularization that many historians of medicine have embraced.
Abel begins her story in the nineteenth century, using the letters and diaries of women who cared for their sick family members at home to show that they accepted death as an ever-present part of life. These familial caretakers provided both physical and spiritual comfort to the dying, while the physician’s intervention was limited to pain management and the occasional prognosis. Those patients who did seek institutional care in hospitals frequently suffered from a lack of medical attention and privacy. By the early decades of the twentieth century, the increasing number of hospitals brought more patients out of the home and under the care of medical professionals. But despite this shift, there remained a remarkable lack of professional attention to the terminally ill. The dying simply were not a priority for physicians and hospital administrators, who were more concerned with teaching medical students, maintaining economic efficiency, and maintaining low mortality rates. Incurable patients were sent away from hospitals to die in sanatoria, almshouses, or private old-age homes, but even these institutions were unable to provide a great deal of care because of staffing and budget limitations.
After World War II, physicians and the public paid more attention to chronic conditions like cancer, but the discourse remained focused decidedly on recovery. Hospitals began to admit more patients, spurred in part by the Hill–Burton Act (1946), the expansion of private insurance, and a greater enthusiasm for medical research that depended on patient-subjects. As hospital admissions increased, the work of creating terminal care plans fell not to doctors and nurses but to social workers. Although these workers could help transfer patients to other care facilities, many patients preferred to return home after discharge. Caring for a loved one at home allowed family [End Page 348] members both to maintain control of the secrecy surrounding a terminal prognosis and to ensure the death was a...