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.

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