Changing patterns of death and dying.

This paper reviews changing patterns of mortality worldwide, paying particular attention to differences between developed and developing countries and the consequences of demographic and epidemiological transitions. These involve gains in life expectancy and a shift from infectious to degenerative conditions as causes of death. Reversals to these transitions in certain Eastern European and African countries, due respectively to the social disorganisation accompanying the collapse of communism and to AIDS is described. The implications of changing population structures for the experience of old age and dying are explored and gender and socio-economic differences within countries is highlighted. The current state of knowledge about differences in the dying trajectories of different causes of death is summarised and gaps in this knowledge identified. The availability of lay health care in the community at different points in the demographic transition is described, and the problems and dilemmas of formal health care provision for dying people in both developed and developing countries outlined, including an analysis of the reasons for public support for euthanasia in some Western countries. In particular, the appropriateness of models of specialist palliative care outside the cultures in which such care originally developed is questioned. Finally, there is discussion of the extent to which medical and scientific measures erode traditional religious consolations for the problems involved in dying and bereavement.