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EXECUTIVE SUMMARY
* With a combined career of over 60 years in oncology nursing, the authors reflect on the critical elements in the question, "How can we afford to die?"
* Three high-profile patient scenarios in three different decades promised to improve use of advance directives but did not.
* Recent societal events, including the debates about health care reform, have brought attention again to end-of-life issues and care.
* Quickly approaching a "perfect storm" of an aging population, an inefficient and costly illnessoriented health care system, and health care profession shortages, the United States will not be able to afford delivering futile interventions.
* Nurses, who are consistently seen as the most trusted professionals, must take action in strategies the authors present.
DURING THE HEIGHT OF THE Affordable Care Act (Strokoff& Grossman, 2010) debate, an editorial cartoon symbolized the perspectives on endof- life choices, with a humorous twist (see Figure 1). Headlines of "death panels" dominated the news for a while, but unfortunately, did not lead to a national conversation on end-of-life care. The purpose of this article is to reflect on the critical elements in the question, "How can we afford to die?" based on our combined career of over 60 years in oncology nursing and to suggest actions that nurses can take in this ongoing debate.
The Past
We both began our oncology nursing careers in the 1970s and witnessed at least three high-pro- file national debates on end-of-life issues (see Table 1). Each of these public debates gave us hope that sweeping and effective societal change toward end-of-life care would occur. The Patient Right to Self-Determination Act of 1990 (H.R. 4449) was passed in 1990 and implemented in 1991, requiring that patients be informed about advanced health care directives on admission to health care institutions. Although this may have been technically implemented, subsequent studies have shown the intent of this legislation has not been widely adopted. Sadly, this is not unusual when the letter of the law is implemented but the intent is missed. In 2010, while 61% of older Ameri cans feared outliving their savings more than they feared dying (Fleck, 2010), only 20%-30% of adult Americans reported having advanced directives (Sedensky, 2010).
Why the paradox? Why the heated...