Always alert for a bit of good
news about the sorry way so many older
Americans die, I noticed a recent report
from the Centers for Disease Control and
Prevention. The agency’s statisticians
looked at the deaths of people over 85 —
700,000 of them in 2007 — and where they
occurred, and pointed out some
encouraging trends.
The proportion of those very
old people who died as hospital patients
dropped to 29 percent in 2007 from 40
percent in 1989. During the same time
period, the proportion who died at home
climbed to 19 percent from 12 percent.
The full C.D.C. report shows
similar trends in the broader population
over age 65: a steadily declining
proportion of deaths in hospitals (just
over one-third in 2007, down from nearly
half in 1989) and a rising proportion of
deaths at home (24 percent in 2007, up
from 15 percent in 1989).
That’s still a very low
percentage, given how many people say
they want to die in their homes. But it
shows improvement, doesn’t it?
Not so fast, said Dr. Joan
Teno, professor of community health and
medicine at the Brown Medical School.
She pointed out to me that the rates of
very old people dying in nursing homes
and other long-term care facilities have
also increased, reaching 40 percent of
those over age 85. If they were actually
residents of the nursing homes in which
they died, that may not be unhappy news.
But if people are being
shuttled from home to hospital to
nursing home (and possibly around again)
during their last days and weeks, that’s
nothing to celebrate. “Site-of-death
data only tells you where you are at
time of death, but nothing about the
transitions leading to that point,” Dr.
Teno said.
In The New England Journal of
Medicine last year, Dr. Teno and her
colleagues published an analysis of
seven years of Medicare data on nearly
half a million nursing home residents
with advanced dementia, a terminal
disease. Almost one in five experienced
what the authors called “burdensome
transitions” in their final days:
transfers in the last three days of
life, multiple hospitalizations, or
moves from nursing home to hospital to a
different nursing home.
So Dr. Teno is glad that more
people were dying in their homes instead
of in intensive care units. “Years ago,
we just kept them in the hospital,” she
said. Still, she added, “I don’t want to
look only at where they die, but at the
kind of care they get” in their last
days and weeks.
Duly noted. The percentage of
very old people dying at home increased
by more than 50 percent over nearly two
decades, but many are still denied the
peaceful passage in familiar
surroundings that we hope for, or
perhaps fantasize about. One and a half
cheers.
