Reforming U.S. Care at Life's End

Aging Today, September/October 2006 | Go to article overview
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Reforming U.S. Care at Life's End

During the 20th century, the average life expectancy of Americans nearly doubled, from just 49 years in 1900 to nearly 80 years in 2000. In the United States today, people can expect longer and healthier lives, but most will spend their last few years living with disabilities or chronic illnesses.

These changes are straining the U.S. healthcare system, which did not develop in the context of needing to serve large numbers of elders with chronic illness and disabilities. In her book Sick to Death and Not Going to Take It Anymore! Reforming Health Care for the Last Years of Life (Berkeley, Calif.: University of California Press, 2004), Joanne Lynn looks at the healthcare available to Americans in the final years of life, the demographic trends that will increase the need for end-of-life care, and the methods available to address effectively the growing need for healthcare at the end of life. Lynn, of the nonprofit research organization the RAND Corporation, concludes in her study that appropriate reforms will require several changes:

* The end of life must be understood as a period that typically spans years, not just weeks or months.

* End-of-life care should be organized according to the kinds of services that groups of people need, rather than by disease diagnosis or where the patients receive care.

* Palliative care and conventional medical treatment should be thoroughly integrated rather than viewed as separate entities.

* Policymakers, healthcare providers, insurers, consumers and family caregivers must work toward deliberate reforms, rather than simply assuming that better care will emerge to meet the growing needs.


The boomer generation will be old enough to begin having high rates of late-life disabilities and progressive chronic illness between 2020 and 2030. In 2030, 22% of the U.S. population (80 million) will be 65 or older, and 2.5% (9 million) will be over age 85. The Congressional Budget Office forecasts that the cost of long-term care will reach $207 billion in 2020 and $346 billion in 2040. Furthermore, the healthcare system will require many more caregivers to provide hands-on attention for the millions who will need it.

The existing healthcare system generally classifies patients by disease and setting of care but this method is becoming less effective because it works poorly for the increasing number of elders who have multiple diseases and need care in more than one setting. Lynn provides a framework that groups the entire population according to their health status, which predicts the types of services they are likely to need.

Lynn notes that healthy people and those with stable chronic illnesses need mostly preventive and acute-care services, such as routine visits to healthcare providers for prevention and health maintenance, as well as emergency medical services. However, individuals with serious chronic illnesses have more complicated needs. Patients in this category typically follow one of three patterns over time. For example, the pattern typical for cancer patients is that they often live with comfort and normal daily functioning for a substantial period. Once the illness becomes advanced, though, the patient's health usually declines rapidly in the final weeks and days preceding death.

Alternatively, patients experiencing organ-system failure often live for a relatively long time with only minor limitations in everyday life. They are likely to suffer intermittent serious health problems with emergency hospitalizations and die suddenly from a related complication.

A third group commonly undergoes prolonged dwindling of health that is typical of dementia, disabling stroke and frailty. These individuals escaped cancer and organ system failure and are likely to die at older ages of neurological failure or frailty caused by multiple factors. The current Healthcare system is poorly prepared to provide appropriate care for the growing numbers of older Americans in this group.

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