In my first year of practice in palliative medicine, I made house calls to patients in South Los Angeles. My patients all lived in neighborhoods that ranked among the city's lowest in both income and life expectancy. In these neighborhoods, people die an average of 10 years earlier than those who live less than 10 miles away. Many of my patients felt that they had barely lived their lives when I showed up, ostensibly to help them "die with dignity."
Death may be humanity's great equalizer, but the inequalities suffered in life – leading to a shorter life expectancy – become inequalities in the experience of dying as well.
When I began my career, I had naïvely assumed that, if time were short, who wouldn't prefer the familiarity of home and palliative medicine's focus on quality of life to the chaotic mess of the hospital? But I've learned that even when my patients accept hospice services, the proverbial "good death at home" is often out of their reach. Fully experiencing the benefits of home hospice requires resources: involved, dedicated family members. Money to afford caregivers, particularly in the absence of involved family members. A neighborhood whose local pharmacy actually stocks opiate medications for severe pain. Insurance that covers stays in nursing homes so that family members can simply be family members instead of caretakers.