The Evolution of End-of-Life Care
Luptak, Marilyn. Social Work and End-of-Life Care for Older People: A Historical Perspective. Health & Social Work 29(1): 7-15, 2004.

Before the advent of modern medicine, people of all ages died in the homes they had lived in all their lives, surrounded by family. But as improved treatments nearly eliminated childhood mortality and required in-patient stays in medical settings, death became increasingly confined to hospitals and nursing homes, where the elderly die out of sight and often out of mind. Like the rest of American society, the social work profession has been slow to react to this sea change in end-of-life care. Marilyn Luptak, PhD, LCSW, surveyed the social work literature and the history of the profession to chart the evolution of social workers' attitudes toward and changing responsibilities for end-of-life care.

Throughout much of the 20th century, social workers in the health care arena focused on emotional aspects of illness, primarily in cancer patients and children. Two key reforms in the 1970s began redirecting social workers' attention to end-of-life issues: the hospice movement and advance directives, which established the right of patients to refuse medical care. Social workers became increasingly involved in hospice care as it expanded in the wake of a hospice benefit added to Medicare in 1983. Still, there remained a dearth of social workers interested in working with the elderly, and gerontological issues were rarely included in social work curriculums.

In 1993, the National Association of Social Workers released a formal policy statement on end-of-life care asserting that people should have the right to determine the kind of care they receive during the dying process. Although only 15 to 20 percent of Americans complete advance directives, social workers are increasingly involved in helping coordinate care for terminally ill patients as well as providing supportive services for patients and families, whether that care is provided in a hospital or hospice setting. By end of the 20th century, gerontological social work and end-of-life issues had finally begun to attract significant attention and make appearances in the social work curriculum, primarily due to efforts supported by large funders, such as the Soros Foundation's Project on Death in America and the Hartford Foundation's Gerontological Social Work Initiative.

Future Directions for Social Work
Improving training for social work students is paramount for improving end-of-life care for America's oldest citizens; social workers themselves rate knowledge of death and dying as one of five key competencies needed to practice social work. Social work groups should also make efforts to improve the presence of social workers in nursing homes. Although one out of five Americans die in nursing homes, regulations requiring social workers in nursing homes are lax on training requirements, and many nursing homes do not offer hospice-style options. Social workers also need to continue researching interventions that can help improve decision-making at end of life, and advocate for systemic change that will allow for improved patient self-determination. Furthermore, the social work profession must be ready to address the impact of new medical technologies as the 21st century progresses, so social workers can continue to improve the dying experiences of America's most vulnerable population.

Posted on March 23, 2003