My auntie is dying from metastatic breast cancer. This week she underwent surgery to remove one more mass under her arm. She is also scheduled to receive another round of radiation in six weeks. My mother observed that her doctors never spoke about her prognosis or chances of surviving the surgery or the radiation. Auntie is almost 80. She has been a heavy smoker since age 14 and her emphysema is so bad she can only walk a few steps before she has to catch her breath.

Auntie is not unique. As many as 1 in 3 Medicare patients undergo surgery during the last year of life, according to a Harvard research study recently published in the Lancet. What does this mean about our cultural attitudes and practices around death and dying? Have we forgotten or chosen to ignore that death is as natural as the changing of the seasons? Has the process of passing away been hijacked and now reduced to a lucrative market niche within the health care industry? Has the prospect of reimbursement for procedures taken precedence over medical ethics?

There are already tremendous financial pressures on Medicare together with other government entitlement programs. The budget deficit and our mounting national debt coupled with the daunting challenge of creating jobs for Americans is burden enough. In addition we are still in the midst of implementing healthcare reform intended to provide expanded access to care for the underserved. Surgery is a powerful lifesaving tool that can extend both how long and how well we live, but all concerned must ensure that it is used appropriately for each of us individually and for all of us collectively.

The study also revealed that, at 12 percent, Hawaii ranks lowest in the nation for Medicare patients who received surgery during the last year of life. I have spoken with a number of thought leaders in health care across the state, and the reason for this is unclear. We would like to think that our island community has a greater respect and deeper understanding of the needs of our people as death draws near. This column recently covered the importance of advance directives, palliative care and hospice, which offer patients the opportunity to clearly communicate their wishes, live out their days with an optimal quality of life and to die with grace, free from suffering to the extent possible.

Most of us wish to consider surgery only if it offers a reasonable chance of a cure and a better, longer life. We all need to be on board to get it right. That includes payers, health service providers, each ohana and above all the person whose time is drawing near. We may have made welcome progress in Hawaii toward this end. Still, as a society we need to do better to support people to prepare for the great journey.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.