The 90-80 Dilemma: The Real American Healthcare Crisis

Wednesday, 04 Jan 2012 10:32

About Dr. Monica Williams-Murphy (120 Posts)

Dr. Monica Williams-Murphy is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital. Through her writing and speaking, she is devoted to transforming the end of life into a time of peace, closure and healing. Media Page

Never heard of the 90-80 Dilemma? That’s because I have just coined the phrase. You see, tied into soaring healthcare costs in this country, is another humanitarian crisis of massive proportions.

 It is this:

A HUGE GAP exists between what Americans want for end-of-life care and what they actually receive.  90% of people wish to die at home, yet nearly 80% of us actually die in institutions (hospitals and nursing homes.)1,2,3

So, how did we end up here? How have we tolerated such an extreme disconnect between our desires and our reality? Such a profound disconnect is fundamentally un-American.

But let me tell you a secret. The 90-80 Dilemma was actually created by US!

This crisis was unintentionally created by our modern beliefs and practices regarding death. Listed below are what I believe to be the 4 core beliefs and practices that have led to this dilemma:

1- Death  is a “medical event” that must be treated  in a medical facility.

2- The use of high technology can “cure” us of death or at least delay it for a later or more appropriate time.

3- We don’t talk about death socially, so therefore, no one plans for it (ex: living wills, powers of attorney, etc).

4- We have lost deep connectedness and intimacy with others in the modern world. This translates into a scramble to keep the actively dying alive at all costs in efforts to gain time for creating closure and saying the things which need to be said.

These four issues have created this very real social crisis and they contribute to the strain that exists within the Medicare/Medicaid systems.

So, now I ask you: How do we solve the 90-80 Dilemma? How do we find a way to allow those who desire it, to pass away in the peace and comfort of their own homes, surrounded by those who love them most; instead of dying alone, in an ICU, in the middle of the night? (Your ideas and comments are welcome on the message board!)

Here are my 4 recommendations to solve this dilemma:

1- Take a natural view of death. Understand that death is a natural event that can usually be comfortably and peacefully managed at home or in a pleasant hospice setting.

2-Understand that the most appropriate use of medical technology at the end of life is the aggressive treatment of pain or any uncomfortable symptoms, and not the selection of medical technology that artificially prolongs the dying process such as ventilators, ICU admissions, and CPR. (See It’s Ok to Die, Chapter 26: Moving from High-Tech to High-Touch Medicine)

3-The above items can be accomplished if we are able to re-introduce death and dying into public conversations. Why should we be afraid to talk about one of the most fundamental facts of life…that it ends? Further, people who can openly discuss death are more likely to make advanced plans, easing the decision-making burden on family and loved ones when “their time” comes.

4-Finally, we must discover the power and gifts inherent in the end-of-life period. In the face of the sure knowledge of coming death, an emotional window of opportunity opens—love may be freely expressed, old grudges may fall away in insignificance, and closure may be obtained that remained elusive at other times of life. We must focus on creating quality of time at the end of life so that these gifts may be enjoyed.


All of us, together, can choose a different way. We can solve the 90-80 Dilemma and create peace and dignity at the end of life. By consciously changing our beliefs and practices regarding death and dying, you may take your last breath in your own bed, held in the arms of those who love you most…as you (and 90% of Americans) wish.


Monica Williams-Murphy, MD


1The Gallup Organization:Knowledge and Attitudes Related to Hospice care. Princeton, NJ: Gallup Organization: September, 1996.

2Emanuel L, von Gunten C, Ferris F. (2000) Gaps in End-of-Life Care. Archives of Family Medicine. 9, 1176-80.

3 Cassel C, and Demel B. (2001) Remembering Death: Public Policy in the USA. Journal of the Royal Society of Medicine. Sept, 94 (9); 433-436.

(Note: The last two articles give data supporting death rate “In institutions” at about 75%, I rounded up and said “nearly 80%’ for stylistic effect in coining “the 90-80 Dilemma”)

Our Book: It's OK to Die

"It's OK to Die" is a ground-breaking book filled with graphic stories straight out of the Emergency Room illustrating how most Americans are completely unprepared for death and dying. In response, the authors have created a unique and comprehensive guide urging EVERYONE to prepare in advance, to assure their own peace and to prevent the suffering of their loved ones.
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