Chapter 4 focused on those patients who, though in the midst of dying processes, are able to participate in decision making regarding their lived experiences of dying. The interests of adult, lucid patients with decisional capacity are at least as varied as there are patients themselves. Further, our own relationship to these patients, our roles and abilities, as well as our knowledge and concern, when carefully considered in light of patient needs and circumstances, may need to be brought to bear on behalf of easing their dying. So, we should not be surprised to find that for some patients, morality requires us to aid them in dying, not simply through passive support but through active application of our skills and roles in their lives and society.

This chapter turns to a different set of patients – namely, those unable to make direct, concurrent decisions about their care in dying. This set of patients does not form a monolithic, homogenous group, and in fact will be viewed under several different kinds of conditions and characterizations.

In 2004, according to the CDC, approximately two-thirds of all deaths in the United States occurred in medically related institutions – hospitals, mostly, but also nursing homes and in-patient hospice settings.