1. 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

2. Top 5 Causes of Death 1900

3. Top 5 Causes of Death 1994

4. Where Do We Die

5. Profile of Older Americans: 2000 Fowles DG, Duncker A, Greenberg, S Administration on Aging, Department of Health and Human Services February 9, 2001 www.aoa.gov/aoa/stats/profile

8. The Graying of America 10505101050510 Millions of Persons 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 198019902000 Changing U.S. Age Distribution SOURCE: AMARA et. al., Looking Ahead at American Health Care (1988) Indicates the Baby-Boom Group 1050510

9. Number of workers supporting each Social Security dependent: 1940 = 41 1950 = 16 1998 = 3.4 2030 = 2.1 (projected) The Ghost of Social Security Editorial, Wall Street Journal, July 12, 00 pg A26

10. 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 65 90% of these people are over the age of 65 5.3 million NH residents projected by 2030 5.3 million NH residents projected by 2030 References: National Center for Health Statistics, Highlights of Trends in the Health of Older Americans: United States, 1994, 1997 USA Today pg B1, Thurs, Sept 30, 1999 Graying of America -- Longterm care

11. 1.3 million nurses aides $6.94 per hour -- average wage 93% annualized turnover The Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for Injury by Lorraine Adams in the Washington Post October 31, 1999 Caregiving in America

12. Can Morbidity be Compressed?

13. 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

14. 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 65 90% of these people are over the age of 65 5.3 million NH residents projected by 2030 5.3 million NH residents projected by 2030 References: National Center for Health Statistics, Highlights of Trends in the Health of Older Americans: United States, 1994, 1997 USA Today pg B1, Thurs, Sept 30, 1999 Graying of America -- Longterm care

15. 1.3 million nurses aides $6.94 per hour -- average wage 93% annualized turnover The Hazards of Elder Care; Overexertion, Assault Put Aides at High Risk for Injury by Lorraine Adams in the Washington Post October 31, 1999 Caregiving in America

16. 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

17. Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

19. Patients dying during last institutional stay 79, 216 (53% ) died in an institutional setting at some time over three year period 41% of VA acute care deaths in ICU as compared to 16.9% under Medicare…

20. Costs of Terminal Stays Annual direct cost of terminal admits: $387,367,000 67% of costs in acute care

21. Average Cost Per Day for Terminal Stays Direct DSS Cost

22. What percent of the VHA Budget is Spent on the Last Year of Life? Of approximately $17,000,000,000 allocated per year by VHA for clinical care 10% 10% is for care in the last year of life is for care in the last year of life For 1.3% of enrolled veterans…