Humans' knowledge of our own mortality creates a conflict with our inborn desire to live. Cultures have grappled with this conflict throughout history. In The Epic of Gilgamesh, one of the earliest known works of literature, the title character wrestles with the concept. The Greek philosopher Epicurus tried to define death in context: “Death does not concern us, because as long as we exist, death is not here. And when it does come, we no longer exist.” Knowledge of our own demise should provide us with the means to influence some of its circumstances, and our choice might not be futile pursuit of the unattainable. Indeed, surveys have shown that when people are asked about such preferences, a majority indicate they would prefer death in hospice, with pain relief and with the support of loved ones, to death in hospital (Last Acts 2002). However, too frequently, these preferences are not honored. In many cases of critical illness, people are given the choice of where to die too late, or not at all.
Randall Krakauer, MD, FACP, FACR, is the national Medicare medical director at Aetna. He is responsible for medical management nationally for Medicare members, including program development and administration. Other key areas of responsibility include the complex geriatric case management program; care management and care coordination programs including Compassionate Care; and evaluation and implementation of new medical management opportunities.