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Many advances in public health and medical technology have contributed to the improved wellbeing and overall longevity of Americans. Such benefits, however, have been offset by a change in the nature and prolongation of the dying process. Daniel Callahan offers a challenge to caregivers in his observation of violent death by technological attenuation, and he sets an agenda to identify a more appropriate approach to the needs of the dying.Over the past quarter century, hospice has increasingly been used as a resource for care at the end of life. However, according to 1995 estimates by the National Hospice Organization (NHO), hospice care presently accounts for only about 15 percent of the care of terminally ill patients in the United States. We will review issues of access and use of hospice services and examine the various institutional, professional, societal, and cultural barriers to hospice principles of care, and consider various options to promote optimal care at the end of life.

A study of the nature and degree of patients' possible acceptance of nurses and physicians' assistants in the performance of tasks usually carried out by physicians indicates a considerable difference in acceptability between an upper middle class community and a lower middle and working class community. The upper middle class community more readily accepted their physician's use of assistants and nurses when compared with the lower middle and working class community. These findings emphasize the importance of possible differences in outcomes when new professional roles are used in various settings.The medical profession is faced with problems of manpower, or¬ ganization, and financing. As pa¬ tients' expectations for medical care rise, the number of primary care phy¬ sicians diminishes. In 1950 the num¬ ber of child health physicians (for 41 million children) was 242 per 100,000 children. The projected manpower for 1970 is 106 child health physicians per