From the hospital’s inception as a shelter in early Christianity, death and dying have been prominent institutional events. Initially, this rite of passage was conceived as divinely ordained and therefore accepted, even welcomed, in anticipation of eternal heavenly bliss. When health became both an individual and social good as part of the Enlightenment’s ideology, death came to be viewed as an opponent, kept at bay through good health management and medical treatment. Thus, as hospitals became medicalized, the very mission that sought to transform them into houses of recovery drastically changed the cultural meaning of institutionalized death. Indeed, dying patients quickly became institutional liabilities. Because of fear of contagion, contact with the dead was minimized. During the 20th century, the management of dying patients concentrated on their physical manifestations in harmony with the basic disease orientation of biomedicine. In spite of their apparent futility, modern deathbed activities in hospitals came to include specialized consultations and an aggressive employment of technology. Based on recent experiences with AIDS, however, changes in management goals, location, and caregiving were meant to once again humanize the dying process and provide it with new meanings and importance within a framework of respect and spirituality.

From their inception in Byzantium, Christian hospitals were communal houses of mercy, refuge, and dying, variously called xenodocheia, xenones and nosokomeia. These guesthouses represented an organized effort for coping with the impact of famines, wars, disease, migrations and pilgrimages. The social welfare function was paramount, and the institutions provided sanctuary, physical care, rest, food, clothing, spiritual comfort and medical consultations for the poor, displaced, and homeless. From the very start, the Church and secular authorities prominently employed their guesthouses for controlling epidemics by separating the sick from the healthy. As houses of segregation, hospitals lodged infected individuals considered threats to society such as lepers and plague victims. Under these circumstances, prominent institutional fixtures such as death and dying were handled mostly outside the boundaries of medicine. Within the Christian religious frame, these occurrences were viewed as gateways to eternal heavenly bliss, a divinely ordained rite of passage anticipated, dreaded, but also welcomed. Sharing beds in crowded wards, inmates routinely witnessed such events with a mixture of fear and comfort.

During the Middle Ages, Christian life was but a brief pilgrimage full of hardships, and hospitals often became the final destinations before the earthly journey ended. Given its prominence as a gateway to heaven, the dying process acquired a certain normative quality known as ars moriendi. Eventually codified and widely circulated, the good death as literary genre became part of efforts by the Church to educate the laity concerning the fundamentals of Christian religion. Based on the notion that life of the soul was infinitely more important than bodily existence, the goal was to shepherd the dying along their path to the other world with a minimum of despair, terror, and sense of misfortune—notably the sometimes painful loss of worldly possessions. Among Christian believers, there were really no good reasons to forestall death. The dying were urged to refocus on their soul’s personal judgment and look forward to eventual resurrection instead of clinging to false hopes of regaining bodily health. Repentance and redemption would facilitate the transition.

The notion of a Christian purgatory came to play an important role. Charitable activities such as preparing and assisting others during their dying through prayers, vigils and masses could lessen the time one was expected to remain there before entering eternal bliss. Especially before the Reformation, armies of lay religious brotherhoods and confraternities supplied the necessary manpower for companionship and the performance of dying rituals. In partnering this momentous transition, practitioners of the art were conscious of the fears and struggles of the dying, attempting to cast the process as a battle between good and evil, Christ and the Devil, the latter tempting moribund persons to cling to their sinful lives and material possessions. Under such circumstances, miraculous recovery could be seen as the result of a pact with the Devil to keep enjoying the pleasures of the flesh.

While insuring a measure of physical comfort, most dying rituals were essentially preparations for the anticipated journey. Spiritual cleansing, confession of sins and absolution, anointing with oil, and communion administered by a priest were standard activities. Together with the laying on of hands, the use of oil represented a general palliative or curative agent to be drunk or applied to the skin. By the eight century, however, the Irish Church recast anointing as an agent of spiritual transformation capable of preparing the recipient for death and passage to eternal life. Communion, for its part, was the nourishment or viaticum needed for the journey to God. Given the impotent state of medicine to prevent death, physicians were precluded from administering remedies until the soul had been properly prepared through confession and the administration of the sacraments.

For the poor and elderly, to die in a hospital was considered a privilege. Even through the 16th century, caregivers kept a close vigil, witnessing the ebbing of life and framing it with prayers and the reading of religious texts. Following death, the bodies were carefully washed, anointed and wrapped, then carried in procession to the hospital’s chapel for a requiem mass. Burial in consecrated ground adjacent to the hospital followed. Masses for the deceased inmates were said once a year at the anniversary of their deaths. Witnessed by both inmates and staff, these actions eloquently conveyed the inevitability if not the desirability of death and ameliorated fears surrounding this passage. A good Christian death remained a central pastoral concern, both inside and outside hospitals, reflection of a religiously cohesive society.

During the Renaissance, as modern European states sought to protect and restore their productive members of society, the original religious shelters came under the jurisdiction of local municipalities and national governments. They now splintered into institutions with somewhat overlapping functions: hospitals, hospices, asylums and prisons. In Catholic countries, large shelters or general hospitals warehoused a broad spectrum of individuals from the old, chronically ill to lunatics, vagrants, and criminals. Many institutions were transformed into houses of rehabilitation. Members serving in the armed forces needed to be mended and returned to active duty or retired as invalids. To serve their needs, nations created networks of military and naval hospitals. Workers were herded into civilian establishments for both physical and moral recovery. Such secular goals led some institutions to hire more members of the medical profession for their caregiving staffs.

By the eighteenth century, state power focused even more on economics and science. Health became both an individual and social good, death an undesirable outcome, kept at bay through good health management and medical treatment. As part of the Enlightenment’s ideology, hospitals came to focus on the physical recovery of diseased individuals and became houses of cure. While shelter, food, clothing, and moral rehabilitation still remained institutional goals, medical and surgical treatments became paramount, at times even life saving. For physicians, death was a natural bodily event reflecting the cessation of vital functions. If powerless to stop the process, the only remaining hope was that patients would die ”without a struggle,” but there were no longer obligations following death.

Thus, as hospitals were medicalized, the very mission that sought to transform them into houses of recovery drastically changed the cultural meaning of institutionalized death, prompting a redrawing of the hospital’s boundaries and displacement of the hospice function. Indeed, dying patients quickly became institutional liabilities since mortality rates reflected hospital performance. High death rates jeopardized their reputation as healing places and decreased public and private support for their upkeep. After 1750, for example, the Royal Infirmary of Edinburgh was proud to consistently boast a low 4% mortality rate among its patients. Only admitting young people with acute, self-limited ailments who could recover spontaneously could achieve this statistical feat. Hospitals also participated in the education of medical and later nursing professionals and contributed decisively towards the creation of new knowledge about health and disease, especially medical theory and practice. Emphasis on systematic clinical observations, treatment and experimentation with drugs, as well as bedside learning transformed hospitals into houses of teaching and research. People selected by academics for experimental management and teaching were segregated in teaching wards and subjected to postmortem dissections.

The overall therapeutic strategy was openly characterized as being palliative. Placebos, for their part, were understood to be drugs of questionable efficacy or regular ones prescribed in low, ineffectual dosages to please hopeless patients. Very sick patients were often discharged well before a fatal outcome could mar the institutional record. Others left voluntarily to die at home surrounded by their family, friends, and possessions. William Cullen, one of Edinburgh’s most prominent physicians, explained in a lecture that “it is a custom in this country that people must not be allowed to die out of sight of their friends,” a practice reminiscent of medieval vigils.

However, the same was no longer acceptable in the medicalized eighteenth-century institution. When Cullen discovered in 1773 “six or seven gossips in the room and as many candles lighted up,” the physician acted quickly. “I had the light carried away, made the persons go out and had the room ventilated” to improve the air. Cullen’s efforts apparently bore fruit: “Next day I found a difference of symptoms,” he told his students. Such assemblies of relatives and friends trying to express social solidarity during the dying now created fears of further environmental contamination in hospital wards as well as the potential for impurity and transmission of disease based on the new tenets of public hygiene. With some exceptions, contact with the dead was minimized because of fear of contagion through removal of the body to special mortuaries before release and burial elsewhere.

Thanks to new advances in knowledge and technology, the early twentieth century witnessed the emergence of hospitals as houses of science. Equipped with clinical laboratories and x-ray facilities for diagnosis and treatment, hospital space was divided according to new medical specialties and equipment. Affiliated with academic institutions, many hospitals were transformed into centers of biomedical research and training. As acute, short-term facilities, they gradually shed their remaining convalescent and dying functions, transferring chronic and terminal individuals to nursing homes and hospices. The management of dying patients came to be focused almost exclusively on arresting or reversing their near fatal condition in harmony with the basic disease orientation of biomedicine. In spite of their apparent futility, deathbed rituals in modern hospitals came to include specialized consultations and an ever more aggressive employment of technology, including sophisticated resuscitation techniques. By waging a relentless war on disease, “medical vitalism” sought doggedly to prolong life regardless of cost.

Only in recent times has medicine come to terms with the futility of actively opposing death. The economics of medicine and the waning of supportive caring environments as well as inadequate pain control in hospitals eventually paved the way for changes. Some pleaded for medicine to embrace the goal of relieving suffering. To organize the dying experience, others concerned with the protection of patient autonomy created mechanisms such as living wills and advanced directories based on individuals' personal preferences. The dying process needed to be humanized and endowed with new meanings within frameworks of respect and spirituality.

The shift owes much to the appearance of AIDS in the early 1980s. Aging, death and dying in America were almost invisible events. The new disease, however, reintroduced the reality of death into public consciousness. To the horror of both sufferers and their caregivers, AIDS and death soon became synonymous. Because of their young age and stigmatized status, persons with AIDS frequently came to express doubts about the meaning of their soon-to-be-truncated lives. Our cultural assumption is that all hospitalizations will be for the better, that lives, if not saved, can at least be significantly prolonged. But in the case of AIDS, modern medicine in the early 1980s revealed embarrassing limitations in its quest to stem the course of opportunistic infections and total impotence to prevent ultimate death. The specter of a slow and painful institutional death seemed a horrible fate, prompting feelings of futility, guilt, and lack of fulfillment. Unlike old people, they lacked a record of accomplishments. Some sufferers were absolutely terrified about the prospects, especially the reality of slowly loosing control over a body ravaged by disease. Would AIDS’ clinical manifestations and moral implications deny its sufferers a good death? Empathetic caregivers could only promise to make the dying process more comfortable through the generous use of painkillers and counseling.

The widely known and hailed San Francisco model of AIDS care epitomized this approach. Defined as a multidisciplinary medical and nursing approach, it was created during the early years of the epidemic and functioned in a ward of the San Francisco General Hospital (SFGH), a combined city and county institution founded in 1857. Both the characteristics of the early population of AIDS sufferers and the clinical aspects of this disease, selectively impacted on local political, scientific and community constituencies, thereby bringing about a development unique in the annals of American health care. SFGH in the early 1980s shared the denial about the reality of AIDS at every level. Many just considered it an ephemeral phenomenon. The majority of the staff—many were Catholic and Filipino-- considered the new patients repulsive--and neglected them. For their part, shunned by other hospitals, the suffering young, gay, middle class Caucasian patients resented finding themselves stranded in a county institution. They were often irate and uncooperative. Thus arose the need for an AIDS clinical coordinator, charged with educating the hospital staff in the complexities of caring for immune deficient patients.

By early 1983, SFGH was in danger of becoming a veritable AIDS hospital. The sheer number of very sick and dying patients and their physical as well as emotional and social needs demanded action. The goal was to provide humane, compassionate treatment. Yet, most people, including members of the gay community, were opposed to the creation of an AIDS unit at the hospital. They feared that such a ward would become a sort of leper colony with even greater stigma and neglect. Eventually, however, a skilled nursing unit made sense for both caregivers and patients. Located in an isolated wing, it offered protection to the rest of SFGH’s patient population. The new 12-bed facility--Ward 5 B--primarily functioned as a combination of critical and hospice care unit with priority given to patient advocacy, care, and education rather than solely concentrate on medical treatments. The medical component was based on earlier oncology models where multidisciplinary issues had to be addressed within a strong primary nursing framework and social support. Skilled nurses with ICU backgrounds staffed the unit; many familiar with hospice and home care. They were mostly gay volunteers, reflecting the ethnicity, sexual orientation and activism of their patients. This very personal commitment to AIDS work and its political dimensions became for many caregivers the very centerpieces of their professional lives.

Dying concerned all patients hospitalized at 5 B. In sharp contrast with the ethos governing most modern hospital wards, this ward appeared in the eyes of many to be a "recruitment center for the morgue." In spite of such somber perceptions, the staff in the unit worked hard to establish a supportive environment that acknowledged the shifting expectations of those who perceived themselves as death row inmates. Volunteers supplemented the official staff. Many circulated freely offering to listen and engage individual patients. Around the holidays, some handed out presents, served gourmet dinners, and offered massages. Humor was one of the most potent weapons to neutralize despair. Patients exercised much greater control over their hospital course, especially in relation to the frequent and very difficult death and dying issues. Persons die the way they live, exhibiting a great variety of responses. Some remained quite fearful and anxious, desperately seeking company and hoping to prolong the process. Others came quietly to terms with their fate, wanting to be left alone and refusing nourishment and medication.

The most important issue about their dying was some measure of control over the event and efforts to infuse it with meaning. Several sufferers had problems with the so-called “death and dying industry” spawned by bio-ethicists during the 1970s. Construction of a new “good death” model involved issues of truth telling, autonomy, and understanding, mediated through a series of terminal care rituals. Did the model articulated by Kübler Ross suggest a normative pathway? While the concept of successive levels and phases in dying shed light on the process, the actual management based on such a framework seemed problematic. At SFGH, lack of a consensus about the “right” way to die hobbled both patients and their caregivers. Some patients even felt guilty: “I am not dying according to plan,” was a frequent complaint. Frustrated, some AIDS sufferers improvised, creating unique blends of traditional religious as well as secular death myths. Both heroism and liberation became associated with this final rite of passage, returning to models employed in the early Christian shelters.
San Francisco's model was profoundly shaped by the realities of AIDS as perceived in the early 1980s when the disease afflicted gay Caucasian men and involved mostly caregivers of similar ethnicity and sexual orientation. Infused with California’s New Age sentimentality, San Francisco--frequently stereotyped as a bastion of extreme liberalism and non-conformity--was an ideal place for this development. With insights into AIDS’s ability to threaten the identity and integrity of gay patients, many caregivers in Ward 5 B claimed to have achieved an intuitive understanding of their patients’ suffering. Sharing meanings and values as well as socio-economic status, both parties established a truly healing kinship, in spite of the therapeutic failures and frequent institutional deaths. Here the hospital once more truly embodied the traditional hospitalitas or gift-relationship between caregivers and patients. However, the model became gradually obsolete as the character of the epidemic changed and new constituencies rushed to seize a segment of the fledgling AIDS industry.

Change and transformation were the only constants in the evolution of hospitals. Their historical development reveals profound shifts in institutional character and functions. In this process of redrawing boundaries and transforming services, modern hospitals have delegated and divested themselves of many of their earlier roles including being shelters for the homeless, soup kitchens for the hungry and downtrodden, churches and convents for the pious. They also came to be isolation facilities for the contagious and jails for the unruly poor, retirement villages for couples and singles, nursing homes for the frail, old and chronically ill as well as hospices for the dying and burial grounds for the dead.

Hospitals originally emerged as communal homes to shelter the needy and deal with their mortality, providing a human touch to those suffering within particular social and religious frameworks. Later, new medical agendas vigorously attempted to recover the health of inpatients and functionally reintegrate them into their families, jobs, and communities. While designed to pamper consumers in increasingly attractive surroundings, the American health care "product" often deprive patients of opportunities for empathic caregiving. Since 21st century hospitals will perform almost exclusively short-term and intensive technological interventions, they need to devise new ways of making that care humane and responsive to patients needs, hopes, and fears. In spite of their desire for sophisticated technology, patients still hunger for human contact. In the end, whether directed towards recovery or death, patient-centered care must involve body and mind. This is especially true in palliative medicine. Given their historical roots, hospitals and hospices must remain traditional monuments to human empathy and benevolence.