Changes in How We Die
• Most deaths now in institutions– Families less able to care for dying patients
• Most deaths due to chronic illness• Dying usually takes a long time• Dying is expensive• Many options available
– Treatments, care systems, where to die
Many now view dying itself as a choice
Top 5 Causes of Death 1900
Rank Cause of Death Percentage
1 Influenza,Pneumonia
11.8
2 Tuberculosis 11.3
3 Gastritis,Enteritis
8.3
4 Heart Disease 8.0
5 Stroke 6.2
Top 5 Causes of Death 1994
Rank Cause of Death Percentage
1 Heart Disease 32.1
2 Cancer 23.5
3 Stroke 6.8
4 COPD 4.5
5 Accidents 3.9
Where Do We Die
50%25%
25%
Other
Nursing Home
Hospital
Profile of Older Americans: 2000Fowles DG, Duncker A, Greenberg, S
Administration on Aging, Department of Health and Human ServicesFebruary 9, 2001 www.aoa.gov/aoa/stats/profile
The Graying of America
1010 55 00 55 1010 1010 55 00 55 1010
Millions of Persons
1010
2020
3030
4040
5050
6060
7070
8080
1010
2020
3030
4040
5050
6060
7070
8080
19801980 19901990 20002000
Changing U.S. Age DistributionChanging U.S. Age Distribution
SOURCE: AMARA et. al., SOURCE: AMARA et. al., Looking Ahead at American Health CareLooking Ahead at American Health Care (1988) (1988)
Indicates the Baby-Boom GroupIndicates the Baby-Boom Group
1010 55 00 55 1010
Number of workers supporting each Social Number of workers supporting each Social
Security dependent:Security dependent:
1940 = 41 1940 = 41
1950 = 161950 = 16
1998 = 3.41998 = 3.4
2030 = 2.1 (projected)2030 = 2.1 (projected)
The Ghost of Social SecurityThe Ghost of Social SecurityEditorial, Wall Street Journal, July 12, 00 pg A26Editorial, Wall Street Journal, July 12, 00 pg A26
• 1.6 million live in US nursing homes 1.6 million live in US nursing homes
• 17,000 long term care facilities. 17,000 long term care facilities.
• 90% of these people are over the age of 90% of these people are over the age of 6565
• 5.3 million NH residents projected by 20305.3 million NH residents projected by 2030References: National Center for Health Statistics, References: National Center for Health Statistics,
Highlights of Trends in the Health of Older Americans: United States, 1994, 1997Highlights of Trends in the Health of Older Americans: United States, 1994, 1997USA Today pg B1, Thurs, Sept 30, 1999 USA Today pg B1, Thurs, Sept 30, 1999
Graying of America -- Longterm careGraying of America -- Longterm care
1.3 million nurses aides1.3 million nurses aides
$6.94 per hour -- average wage$6.94 per hour -- average wage
93% annualized turnover93% annualized turnover
The Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for InjuryThe Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for Injuryby Lorraine Adams in the Washington Post by Lorraine Adams in the Washington Post
October 31, 1999October 31, 1999
Caregiving in AmericaCaregiving in America
Can Morbidity be Compressed?
Possible issues for discussion
• Where we will grow old and die
• Economics of such care
• Palliative care issues in specific venues:– Home Care, Nursing
Homes, Assisted Living, Hospitals
• Personal and Cultural changes associated with demographic changes
• Technical advances in provision of palliative care
• Education issues– Professionals
– Lay Public
• Advocacy
• 1.6 million live in US nursing homes 1.6 million live in US nursing homes
• 17,000 long term care facilities. 17,000 long term care facilities.
• 90% of these people are over the age of 90% of these people are over the age of 6565
• 5.3 million NH residents projected by 20305.3 million NH residents projected by 2030References: National Center for Health Statistics, References: National Center for Health Statistics,
Highlights of Trends in the Health of Older Americans: United States, 1994, 1997Highlights of Trends in the Health of Older Americans: United States, 1994, 1997USA Today pg B1, Thurs, Sept 30, 1999 USA Today pg B1, Thurs, Sept 30, 1999
Graying of America -- Longterm careGraying of America -- Longterm care
1.3 million nurses aides1.3 million nurses aides
$6.94 per hour -- average wage$6.94 per hour -- average wage
93% annualized turnover93% annualized turnover
The Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for InjuryThe Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for Injuryby Lorraine Adams in the Washington Post by Lorraine Adams in the Washington Post
October 31, 1999October 31, 1999
Caregiving in AmericaCaregiving in America
Veteran Deaths – Basic Facts
• 29% of Americans dying each year are veterans• The majority of dying veterans are not enrolled for
by care by VA• A majority of enrolled veterans do not die in VA
facilities• A small shift of very sick and dying veterans not
currently served by VA into the VA could swamp the system
Annual Veteran Deaths
A small percentage of veterans die as inpatients in VA facilities
National VA Mortality by VISN FY2000
0
500
1000
1500
2000
2500
3000
VISN
# Dea
ths b
y Loc
ation VAMC Total Deaths
Hospital Deaths
Nursing Home Deaths
Patients dying during last institutional stay
• 79, 216 (53% ) died in an institutional setting at some time over three year period
27%
38%
17%
8%
10% ICU Deaths
Acute Care Deaths
NHC Deaths
Ded. Palliative Care BedDeaths (est)
Deaths in Other Setting
41%41% of VA acute care deaths of VA acute care deaths in ICU as compared to in ICU as compared to 16.9%16.9%
under Medicare…under Medicare…
Costs of Terminal Stays
Percentage total cost by venue
38%
29%
18%
4%
11%ICU Deaths
Acute Care Deaths
NHC Deaths
Ded. Palliative CareDeaths
Other Setting
Annual direct cost of terminal admits: $387,367,000
67% of costs in acute care
Average Cost Per Day for Terminal Stays
$0$500
$1,000$1,500$2,000
ICU Acute Care NursingHome
PalliativeCare
Direct DSS CostDirect DSS Cost
What percent of the VHA Budget is Spent on the Last Year of Life?
Of approximately Of approximately $17,000,000,000 allocated per $17,000,000,000 allocated per year by VHA for clinical care year by VHA for clinical care
10%10%
is for care in the last year of is for care in the last year of lifelife For 1.3% of For 1.3% of
enrolled veterans…enrolled veterans…
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
National Palo Alto Lebanon Dayton
National vs three stations with palliative care units
FY 2000 Inpatient Deaths by Location
ICU (all)
General Medicine
Intermediate Medicine
Nursing Home
