PARIS – It's easy to believe the French are masters at the art of life when it's April in Paris.

The French are less successful at death.

"Now almost 70 percent in France die in a hospital," said Dr. Julia Revnic, a palliative care specialist at the Hôtel-Dieu Hospital across the street from Notre Dame Cathedral. "Dying isn't natural anymore. To die today has become a medical act."

Like Americans, the French would prefer to die at home. If the end of life involves a chronic disease, that isn't always possible.

Hospice and palliative care are designed to ease the discomfort and indignities that can beset a dying patient, and 38 percent of Americans now die in hospice care, according to the National Hospice and Palliative Care Organization. But this is still relatively new to French medicine.

Palliative care at Hôtel- Dieu is handled on an outpatient basis, with no hospice facility. Hospices in Paris focus on the mental well-being of dying patients and less on medical care offering comfort and pain relief, Revnic said.

The cost of dying in a hospital is driving change.

"This is an economic bomb for our [national health] insurance," said Dr. Jean-Michel Lassaunière, head of palliative care at Hôtel-Dieu. "Palliative care is a new paradigm now for medicine, because, for technical medicine, the cost is now in front of the wall."

We have seen this wall in the United States as well. For people who don't die suddenly, the health care received in the last six months of life is the most expensive.

End-of-life care accounts for 27 percent of Medicare expenditures, which this year are estimated at $506 billion. A recent study of 160,000 Medicare patients published in The Archives of Internal Medicine found spending in the last six months of life ranged from $20,166 for whites to $26,704 for blacks to $31,702 for Hispanics.

Although the study did not identify reasons for the disparity, the French experience with end-of-life care suggests cultural background and an absence of dialogue between patients and physicians may be part of it.

The Catholic backgrounds of France, Spain and Italy have made decisions about stopping intensive medical care techniques for terminally ill patients particularly difficult, Lassaunière said.

"Europe is divided over whether to allow patients to halt treatment up to euthanasia," he said. "The Catholic culture resists this, while Protestant societies are more willing."

France passed a law in 2005 giving patients the right to determine in advance what interventions they want and requiring doctors to discuss such acts with patients and their families.

"The law requires a right for the patient not to be forced beyond reasonable treatment," said Revnic.

Dying in hospice care rather than a hospital is supposed to focus the experience on comforting the patient, medically and spiritually. It also costs less. A 2007 Duke University study of Medicare patients found hospice care was, on average, $2,300 less expensive than hospital care.

In Texas, 72,566 Medicare patients received hospice care in 2007, staying an average of 78 days at a cost of $10,847. Both the cost and duration numbers for Texas were slightly above the national average.

One in five Texans dies in a hospital – still an uncomfortable prospect, but a level the French would envy.

"All of us want to be young until we are 90 years old, with no depression, no anxiety, and to have wonderful skin and so on," Revnic said. "But this technology of extending life has to remember the patient, and to remember that dying is a natural part of living."