Special Feature on Death and Dying

Publication Details

Introduction

This year’s Chartbook includes 18 charts on our Special Feature: Death and Dying.

Death and dying are complex processes with implications for individuals, their families and friends, their care providers, and the health care system. In 2007 in the United States, nearly 2.5 million people died. Those 85 years of age and over accounted for 29% of deaths, but people of all ages died and from various causes. Adequate preparation for death, and appropriate end-of-life care, may be hampered by the difficulty in predicting when death will occur, even for those with serious or terminal illnesses.

For persons who are dying, and their families and friends, the circumstances surrounding the event can result in a more (or less) comfortable and dignified experience. Death can be instantaneous, or dying can be a drawn-out process that is either relatively comfortable (“a good death”) or painful and undignified. Dying can also be a great emotional and financial burden on families and caregivers. Because it can be associated with both physical and emotional pain and discomfort—which may be mitigated with proper support for the individual and those close to them—dying can be considered a major public health issue (1).

Dealing with death and dying is a personal process, influenced by culture, one’s beliefs, how different health care providers communicate information and advice about prognosis, and many other individual and societal factors (2,3). Some people and cultures discourage talk about the possibility of dying, even when faced with a terminal illness, perhaps because they, their families, or their care providers do not want to give up hope of recovery (2). Others diagnosed with a terminal illness assertively seek out information to help them plan their end-of-life medical care and other needed services. Research suggests that end-of-life discussions may be associated with less aggressive medical care near death and with earlier referral to hospice services. Aggressive care for some terminal conditions, on the other hand, has been associated with worse patient quality of life and worse bereavement adjustment (2).

When asked, most terminally ill patients, their families, and their medical care providers agree that the most important aspects of dying include having a designated decision maker, knowing what to expect about prognosis and physical condition, maintaining dignity, having one’s financial affairs in order, and being free of pain (4). Yet even for patients enrolled in a hospice care program that has the stated purpose of making the dying process more comfortable, one-third of decedents had pain near the time of death (Figure 40). Nine-tenths of hospice care patients had on file some form of advance directive that stated their preferences in case of incapacitation, particularly immediately before death. The use of advance directives was less common among nursing home residents, with just over two-thirds of residents 65 years of age and over having some form of advance directive (Figure 36).

Figure 24 consists of two pie charts showing the distribution of United States deaths for all ages, by age and cause of death, for 2007.

Figure 24Deaths for all ages, by age and cause of death: United States, 2007

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NOTE: CLRD is chronic lower respiratory diseases. See data table for Figure 24.

SOURCE: CDC/NCHS, National Vital Statistics System.

The emphasis in the United States on conquering disease—combined with the uncertainty of predicting when death will occur—can lead to intense and costly efforts to prolong life, sometimes resulting in great discomfort, loss of function, and diminished quality of life for the dying person (1). Medical technology has helped save lives, but it also can prolong life for the critically ill, unresponsive patient who has little or no chance of recovery. Services such as mechanical ventilation, dialysis, parenteral (tube) feeding, and other means can keep even comatose and “brain dead” patients alive, making the very definition of death controversial (5,6).

For the health care system, dying can be extremely expensive, particularly when hospital intensive care unit (ICU) or critical care services are used. About one in five Americans died during a hospitalization that involved the use of ICU services (7). The average length of stay for terminal ICU hospitalizations was 12.0 days, with costs of $24,541—compared with 8.9 days and $8,548 for non-ICU terminal hospitalizations (7). Many studies have found that health care expenditures are concentrated at the end of life and are often interpreted as “the high cost of dying” (8,9).

This Special Feature focuses on death and dying in the United States. Data are presented on trends in the leading causes of death by age group and place of death, as well as characteristics of patients receiving hospice care and the services received by hospice care patients’ families. Types of medications patients receive from hospice care are also highlighted. State data include preventable deaths (e.g., motor-vehicle traffic fatalities) and average number of intensive care days in the last 6 months of life for Medicare beneficiaries. Knowing more about the circumstances surrounding death, including who dies, and when, where, and how, can help policymakers, practitioners, and others target resources to reduce preventable deaths and to improve the quality of the dying process for patients and their families and friends.

References

1.
Rao JK, Anderson LA, Smith SM. End of life is a public health issue. Am J Prev Med. 2002;23(3):215–20. [PubMed: 12350455]
2.
Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665–73. [PMC free article: PMC2853806] [PubMed: 18840840]
3.
Gruenewald DA, White EJ. The illness experience of older adults near the end of life: A systematic review. Anesthesiol Clin. 2006;24:163–80. [PubMed: 16487901]
4.
Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476–82. [PubMed: 11074777]
5.
Thomas AG. Continuing the definition of death debate: The report of the President’s Council on Bioethics on controversies in the determination of death. Bioethics. 2010 [PubMed: 20345406]
6.
Controversies in the Determination of Death: A White Paper by the President's Council on Bioethics [online] Washington, DC: The President's Council on Bioethics; 2008. Available from: http://www​.thenewatlantis​.com/docLib/20091130​_determination_of_death.pdf.
7.
Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD. Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med. 2004;32(3):638–43. [PubMed: 15090940]
8.
Scitovsky AA. The high cost of dying: What do the data show? 1984. Milbank Q. 2005;83(4):825–41. [PMC free article: PMC2690284] [PubMed: 16279969]
9.
Levinsky NG, Yu W, Ash A, Moskowitz M, Gazelle G, Saynina O, Emanuel EJ. Influence of age on Medicare expenditures and medical care in last year of life. JAMA. 2001;286:1349–55. [PubMed: 11560540]

Infant Mortality

Infant mortality rates declined by 5%–8% between 1997 and 2007.

The infant mortality rate—the risk of death during the first year of life—is related to the underlying health of the mother, public health practices, socioeconomic conditions, and availability and use of appropriate health care for infants and pregnant women. The 2007 infant mortality rate of 6.75 per 1,000 live births was 7% lower than in 1997. During the same period, the neonatal mortality rate (deaths under 28 days of age) decreased 8%, to 4.41 per 1,000 live births, and the postneonatal mortality rate (deaths from 28 days to 11 months of age) decreased 5%, to 2.33 per 1,000 live births. In 2007, congenital malformations, low birthweight, and sudden infant death syndrome (SIDS) were the three leading causes of infant deaths, accounting for 45% of the 29,000 infant deaths that occurred (1).

Large disparities in infant mortality rates by race and Hispanic origin of the mother persist. In the past 10 years, the infant mortality rate was consistently highest for infants of non-Hispanic black mothers (Table 15). Infant mortality rates were also higher among infants of American Indian or Alaska Native mothers and mothers of Puerto Rican descent than for other racial and ethnic groups. Infants of Central and South American mothers, Asian or Pacific Islander mothers, and Cuban mothers had lower infant mortality rates than other racial and ethnic groups (2). However, substantial variation in birth outcomes exists within subgroups of the Asian or Pacific Islander population (3). During this period, infant mortality rates for non-Hispanic black mothers were three times the rates for Cuban mothers (Table 15).

Figure 25 consists of a line graph and a pie chart showing infant, neonatal, and postneonatal mortality rates and causes of infant deaths, for 1997 through 2007.

Figure 25Infant, neonatal, and postneonatal mortality rates: United States, 1997–2007

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NOTES: SIDS is sudden infant death syndrome. See data table for Figure 25.

SOURCE: CDC/NCHS, National Vital Statistics System.

References

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.
2.
Mathews TJ, MacDorman MF. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Infant mortality statistics from the 2006 period linked birth/infant death data set. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_17.pdf. [PubMed: 20815136]
3.
Schempf AH, Mendola P, Hamilton BE, Hayes DK, Makuc DM. Perinatal outcomes for Asian, Native Hawaiian, and Other Pacific Islander mothers of single and multiple race/ethnicity: California and Hawaii, 2003–2005. Am J Public Health. 2010;100(5):877–87. [PMC free article: PMC2853636] [PubMed: 20299645]

Child Mortality Rates by Organisation for Economic Co-operation and Development (OECD) Country

The United States has a higher child mortality rate than most other OECD member countries.

Child mortality (deaths at 1–19 years of age) rates are lower than for any other age group. However, they vary considerably across countries. The U.S. child mortality rate (32.7 per 100,000 children) was the second highest among the member countries of OECD (1). Rates for other OECD countries ranged from 14.8 per 100,000 children in Luxembourg (average annual 2003–2005) to 34.6 per 100,000 children in Portugal (average annual 2001–2003).

Child mortality rates exclude infants because most neonatal and postneonatal deaths are due to different causes than those of children and adolescents. Unintentional injuries (accidents) were the leading cause of death among children in the United States and Europe (2,3). Among 1–4 year olds, motor-vehicle accidents were the leading cause of unintentional injury death in the United States, whereas drownings were the most common cause of unintentional injury death in Europe (4). Motor-vehicle injuries are the leading cause of unintentional injury deaths among older children in both the United States and Europe. Among the other top causes of death to children in the United States and Europe were birth defects (congenital malformations, deformations, and chromosomal abnormalities), homicide, cancer, and heart disease. Among adolescents (15–24 years of age), suicide was a leading cause of death (Figure 28).

The vast majority of child deaths occur in the developing world, where the leading causes differ from those in OECD countries. They include diarrhea, pneumonia, measles, malaria, human immunodeficiency virus (HIV)/AIDS, and malnutrition (5,6).

Figure 26 is a bar chart showing death rates among children 1 through 19 years of age, by Organisation for Economic Co-operation and Development country, presenting a 3-year average of most recent data, for 2001 through 2006.

Figure 26Death rates among children 1–19 years of age, by OECD country: 3-year average of most recent data, 2001–2006

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NOTES: OECD is Organisation for Economic Co-operation and Development. Data for Belgium are for 1995–1997; data for Denmark are for 1999–2001. See data table for Figure 26.

SOURCE: World Health Organization.

References

1.
OECD StatExtracts. Organisation for Economic Co-operation and Development; Child well-being [online] Available from: http://stats​.oecd.org/Index.aspx.
2.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.
3.
Sethi D, Towner E, Vicenten J, Segui-Gomez M, Racioppi F. European report on child injury prevention. Copenhagen: World Health Organization; 2008. Available from: http://www​.euro.who.int​/__data/assets/pdf_file​/0003/83757/E92049.pdf.
4.
World Health Organization, Europe. Fact sheet. Copenhagen and Rome: WHO; 2008. Tackling injuries, the leading killers of children. Available from: http://www​.euro.who.int​/__data/assets/pdf_file​/0006/98601/FS​_TacklingInjuries_Children.pdf.
5.
Patten GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: A systematic analysis of population health data. Lancet. 2009;374(9693):881–92. [PubMed: 19748397]
6.
Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet. 2005;365(9465):1147–52. [PubMed: 15794969]

Deaths Among Children 1–14 Years of Age

The death rate among children 1–14 years of age decreased 22% from 1997 to 2007.

Almost 11,000 U.S. children 1–14 years of age died in 2007. Unintentional injuries were the leading cause of death, accounting for 35% of deaths in this age group in 2007. The unintentional injury death rate dropped 30%, from 9.6 per 100,000 children in 1997 to 6.7 per 100,000 children in 2007.

Cancer was the second leading cause of death for 1–14 year olds. In 2007, about 1,300 children 1–14 years of age died from cancer, representing 12% of deaths in this age group. In 2007, the cancer death rate was 2.3 per 100,000 children, 15% lower than in 1997. Congenital malformations, deformations, and chromosomal abnormalities were the third leading cause of death in this age group, representing 9% of deaths. About three-fifths (59%) of deaths in this age group from congenital malformations were among children 1–4 years of age (1). Death rates from congenital malformations decreased 16% between 1997 and 2007.

Homicide was the fourth leading cause of death, accounting for 7% of deaths in this age group. Children 1–4 years of age accounted for 53% of homicide deaths in this age group (1). Homicide rates among children 1–14 years decreased 13% between 1997 and 2007.

Heart disease was the fifth leading cause of death for children in this age group in 2007, accounting for 414 deaths—4% of all deaths to children 1–14 years of age.

Figure 27 consists of a line graph and a pie chart showing United States death rates for leading causes of death among children 1 through 14 years of age, for 1997 through 2007.

Figure 27Death rates for leading causes of death among children 1–14 years of age: United States, 1997–2007

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NOTE: See data table for Figure 27.

SOURCE: CDC/NCHS, National Vital Statistics System.

Reference

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.

Deaths Among Persons 15–24 Years of Age

Death rates from unintentional injuries—the leading cause of death for persons 15–24 years of age—increased 5% between 1997 and 2007.

In 2007, there were about 34,000 deaths among persons 15–24 years of age (1). The overall death rate for this age group was stable from 1997 to 2007. Unintentional injuries were the leading cause of death for teens and young adults throughout this period, accounting for almost one-half of deaths in 2007. Between 1997 and 2007, the death rate for unintentional injuries increased 5% for this age group. The majority of unintentional injury deaths resulted from motor-vehicle traffic injuries (Table 37). Motor-vehicle traffic-related death rates were more than twice as high among males as females.

Homicide was the second leading cause of death in this age group during this period, accounting for 16% of deaths in 2007. Between 1997 and 2000, the homicide rate declined and then stabilized. In 2007, the homicide death rate was six times as high for males as for females ages 15–24 years and was higher among African American males and Hispanic males than among non-Hispanic white males in this age group (Table 38).

Since 1997, the suicide death rate—the third leading cause among this age group—declined from 11 to 10 per 100,000 population. Suicide death rates were five times as high among males as females in this age group in 2007 (Table 39).

Death rates for the next leading causes of death, cancer and heart disease, decreased about 10% for this age group between 1997 and 2007.

Figure 28 consists of a line graph and a pie chart showing United States death rates for leading causes of death among persons 15 through 24 years of age, for 1997 through 2007.

Figure 28Death rates for leading causes of death among persons 15–24 years of age: United States, 1997–2007

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NOTE: See data table for Figure 28.

SOURCE: CDC/NCHS, National Vital Statistics System.

Reference

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.

Deaths Among Persons 25–44 Years of Age

Between 1997 and 2007, the death rate among persons 25–44 years of age declined 7%, primarily due to a reduction in cancer and HIV-related deaths.

In 2007, there were 122,000 deaths among persons 25–44 years of age. Between 1997 and 2007, the overall death rate among persons in this age group declined 7%. During this period, the death rate for unintentional injuries—the leading cause of death for this age group—increased 21%, from 31 to 38 deaths per 100,000 population. In 2007, 42% of unintentional injury deaths were from poisoning (1).

Death rates for cancer—the second leading cause of death during this period—decreased 21%, from 25 to 20 deaths per 100,000 population. Lung, brain, and colon cancers were the leading causes of cancer death among men in this age group, and breast, lung, and cervical cancers were the leading causes of cancer death among women in this age group (2) (Tables 33 and 34). Death rates for the third leading cause of death, heart disease, were stable during this period (Table 30).

Death rates for suicide (the fourth leading cause) and homicide (the fifth leading cause) were stable for persons 25–44 years of age between 1997 and 2007. Suicide and homicide death rates were generally three times higher among men than women in this age group (Tables 38 and 39).

Death rates for human immunodeficiency virus (HIV) disease, the sixth leading cause of death in 2007, decreased by more than one-half, from 13 to 6 per 100,000 population in 2007. After rising rapidly in the late 1980s and early 1990s, the HIV disease death rate fell sharply in the mid- to late 1990s with the introduction of antiretroviral therapies (3,4). In 2007, HIV accounted for 4% of deaths among this age group.

Figure 29 consists of a line graph and a pie chart showing United States death rates for leading causes of death among persons 25 through 44 years of age, for 1997 through 2007.

Figure 29Death rates for leading causes of death among persons 25–44 years of age: United States, 1997–2007

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NOTE: See data table for Figure 29.

SOURCE: CDC/NCHS, National Vital Statistics System.

References

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.
2.
CDC/NCHS. Compressed Mortality File: Underlying cause of death—Mortality for 1999–2006 with ICD–10 codes [online] WONDER online database. Compiled from Compressed Mortality File 1999–2006, Series 20 no 2L. 2009. Available from: http://wonder​.cdc.gov/cmf-icd10.html.
3.
CDC. HIV and AIDS—United States, 1981–2000. MMWR. 2001. pp. 430–4. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5021a2.htm. [PubMed: 11475378]
4.
CDC. HIV/AIDS surveillance report. Atlanta, GA: CDC; 2000. 2001. pp. 3–41. Available from: http://www​.cdc.gov/hiv​/surveillance/resources​/reports/2000report_no2/

Deaths Among Persons 45–64 Years of Age

The death rate among adults 45–64 years of age decreased 8% from 1997 to 2007. Cancer and heart disease accounted for 54% of deaths in this age group in 2007.

In 2007, there were 472,000 deaths among 45–64 year olds in the United States (1). Chronic diseases accounted for five of the six leading causes of death in this age group. The first and second leading causes of death were cancer and heart disease, which accounted for 54% of deaths in this age group. Between 1997 and 2007, cancer death rates decreased 15%, to 200 per 100,000 population. Heart disease death rates declined even more, by 25%, to 134 per 100,000 population.

Unintentional injury was the third leading cause of death in this age group, accounting for 7% of deaths in 2007. Between 1997 and 2007, death rates for unintentional injuries rose 42%. Unintentional poisoning accounted for 37% of unintentional injury deaths for this age group in 2007 (1).

Diabetes, stroke, and chronic lower respiratory diseases (CLRD), the fourth, fifth, and sixth leading causes of death, respectively, each accounted for 4% of deaths to persons in this age group in 2007. Diabetes and CLRD death rates remained stable between 1997 and 2007, while the stroke death rate for 45–64 year olds decreased 19% during this period, from 27 to 22 per 100,000 population.

Figure 30 consists of a line graph and a pie chart showing United States death rates for leading causes of death among persons 45 through 64 years of age, for 1997 through 2007.

Figure 30Death rates for leading causes of death among persons 45–64 years of age: United States, 1997–2007

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Notes: CLRD is chronic lower respiratory diseases. See data table for Figure 30.

SOURCE: CDC/NCHS, National Vital Statistics System.

Reference

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.

Deaths Among Persons 65 Years of Age and Over

Heart disease, cancer, stroke, and influenza and pneumonia death rates decreased over the past decade among older adults, while death rates due to Alzheimer’s disease increased.

Almost three-quarters of all deaths in the United States occur among persons 65 years of age and over, accounting for about 1.8 million deaths in 2007 (1). During the past decade, overall death rates have declined by 8% for this age group.

The death rate for heart disease—the leading cause of death for persons 65 years of age and over—and stroke, the third leading cause, declined by one-quarter between 1997 and 2007. The death rate for cancer, the second leading cause of death for this age group, decreased by 8%. The death rate for the fourth leading cause of death, chronic lower respiratory diseases (CLRD), was stable in the past decade.

In 2007, the fifth leading cause of death among persons 65 years of age and over was Alzheimer’s disease, which accounted for 4% of deaths in this age group. Between 1999 and 2007, the death rate for Alzheimer’s disease increased more than 50%, from 127 to 195 per 100,000 population.

In 2007, diabetes, the sixth leading cause of death, and influenza and pneumonia, the seventh leading cause of death, each accounted for about 3% of deaths in persons 65 years and over. Since 1999, influenza and pneumonia deaths decreased 26%.

Figure 31 consists of a line graph and a pie chart showing United States death rates for leading causes of death among persons 65 years of age and over, for 1997 through 2007.

Figure 31Death rates for leading causes of death among persons 65 years of age and over: United States, 1997–2007

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NOTE: CLRD is chronic lower respiratory diseases. See data table for Figure 31.

SOURCE: CDC/NCHS, National Vital Statistics System.

Reference

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.

Motor-vehicle Traffic Fatalities

During 2000–2007, average annual age-adjusted motor-vehicle traffic death rates ranged from 31 per 100,000 population in Mississippi to 7 per 100,000 population in Massachusetts.

Motor-vehicle traffic deaths—a significant cause of preventable death—accounted for about 42,000 deaths in the United States in 2007 (1). Between 2000 and 2007, the age-adjusted motor-vehicle traffic death rate was stable at about 15 per 100,000 population (1,2).

Nationwide, alcohol-impaired driving is a major risk behavior associated with motor-vehicle traffic fatalities and accounted for 32% of motor-vehicle traffic fatalities in the United States in 2008 (3). Alcohol-impaired driving fatality rates declined 7%, from 0.43 to 0.40 per 100 million vehicle miles traveled, between 2007 and 2008 (3).

Lap and shoulder seat belts, when used, reduce the risk of fatal injuries to front-seat passenger car occupants and the risk of moderate-to-critical injury (4). Over one-half (55%) of passenger vehicle occupant fatalities were among unrestrained occupants in 2008 (4). Seat belt use was lower in rural than urban areas (5).

In 2000–2007, the average annual age-adjusted motor-vehicle traffic death rate varied fourfold by state (6). The five states with the highest age-adjusted rates (25–31 per 100,000 population) were Mississippi, Wyoming, Montana, Arkansas, and Alabama. Age-adjusted motor-vehicle traffic death rates were higher in the most rural areas (non-metropolitan, noncore areas) compared with the most urban areas (large central metropolitan areas) (2). Even after controlling for vehicle miles traveled, motor-vehicle fatality rates in rural areas were greater than in urban areas (5).

Figure 32 is a map of the United States showing unintentional motor-vehicle traffic death rates, by state, for 2000 through 2007.

Figure 32Unintentional motor-vehicle traffic death rates, by state: United States, 2000–2007

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NOTE: See data table for Figure 32.

SOURCE: CDC/NCHS, National Vital Statistics System.

References

1.
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www​.cdc.gov/nchs​/data/nvsr/nvsr58/nvsr58_19.pdf.
2.
CDC/NCHS. Compressed Mortality File: Underlying cause of death—Mortality for 1999–2006 with ICD–10 codes [online]. WONDER online database. Compiled from Compressed Mortality File 1999–2006, Series 20 no 2L. 2009. Available from: http://wonder​.cdc.gov/cmf-icd10.html.
3.
National Highway Traffic Safety Administration (NHTSA) Alcohol-impaired driving. Traffic safety facts, 2008 data. Washington, DC: NHTSA; DOT HS 811 155. Available from: http://www-nrd​.nhtsa​.dot.gov/Pubs/811155.pdf.
4.
National Highway Traffic Safety Administration (NHTSA) Occupant protection. Traffic safety facts, 2008 data. Washington, DC: NHTSA; DOT HS 811 160. Available from: http://www-nrd​.nhtsa​.dot.gov/Pubs/811160.pdf.
5.
National Highway Traffic Safety Administration (NHTSA) Rural/Urban comparison. Traffic Safety Facts, 2007 data. Washington, DC: NHTSA; DOT HS 810 996. Available from: http://www-nrd​.nhtsa​.dot.gov/Pubs/810996.pdf.
6.
Web-based Injury Statistics Query and Reporting System (WISQARS) [online] CDC, National Center for Injury Control and Prevention; Available from: http://www​.cdc.gov/injury/wisqars/index​.html.

Place of Death, Over Time

Between 1989 and 2007, there was a shift in the places where Americans die, with more people dying at home and fewer dying in institutional settings.

When surveyed, most Americans express a preference to die in their homes (1), yet most die in institutional settings. Factors that affect the place of death include individual preference, cultural beliefs, access to care, age, cause of death, social support, and race and ethnicity (1–4). Health insurance coverage, and policies and services used around the time of death—such as hospice care services or nursing home care—are also related to the place of death.

Since 1989, there has been a shift in where Americans die. Although most still are pronounced dead while in nursing homes or hospitals, in 2007 one-quarter died at home—up from one-sixth in 1989. Between 1989 and 2007, more people died in nursing homes or long-term care settings. These increases have been met by a decline in the percentage of Americans dying while hospital inpatients, down to 36% in 2007 from 49% in 1989. This shift in place of death was found both for decedents under age 65 and those 65 and over. From 1989 to 2007, there was an increase of more than 50% in the percentage of deaths at home and a decline of more than 20% in the percentage while hospital inpatients for both age groups.

Age is a significant factor related to where Americans die (3). Older persons may have had greater opportunity to plan for their deaths, and place of death is related to the location of recent care. In 2007, decedents under age 65 were more likely to die at home (30%) than those 65 and over (24%). Older decedents were five times more likely to die in nursing homes than those under age 65.

Figure 33 consists of two bar charts showing the place of death, at home, in the hospital, or in a nursing home, for decedents under 65 years of age and those 65 years of age and over, for 1989, 1997, and 2007.

Figure 33Place of death, over time: United States, 1989, 1997, and 2007

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NOTE: See data table for Figure 33.

SOURCE: CDC/NCHS, National Vital Statistics System.

References

1.
Grunier A, Mor V, Weitzen S, Truchil R, Teno J, Roy J. Where people die: A multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007;64(4):351–78. [PubMed: 17684107]
2.
Johnson KS, Kuchibhatala M, Sloane RJ, Tanis D, Galanos AN, Tulsky JA. Ethnic differences in the place of death of elderly hospice enrollees. J Am Geriatr Soc. 2005;53(12):2209–15. [PubMed: 16398911]
3.
Flory J, Yinong YX, Gurol I, Levinsky N, Ash A, Emanuel E. Place of death: U.S. trends since 1980. Health Aff (Millwood) 2004;23(3):194–200. [PubMed: 15160817]
4.
Institute of Medicine. Field MJ, Cassel CK, editors. Approaching death: Improving care at the end of life. Washington, DC: National Academy Press; 1997. Available from: http://www​.nap.edu/catalog​.php?record_id=5801.

Place of Death, by Age and Race and Hispanic Origin

Among decedents 65 years of age and over, non-Hispanic white decedents were less likely to die while hospitalized and more likely to die in nursing homes than decedents in other racial and ethnic groups.

Race and ethnicity have been identified as factors affecting end-of-life care and place of death (1–7). When surveyed, white persons are more likely to have expressed a preference to die at home compared with black and Hispanic persons (4,6). Hispanic and black persons are less likely to use hospice care than white persons, and Hispanic survey respondents express a preference not to place relatives in nursing homes. Previous studies have shown that non-Hispanic white decedents are less likely to die while hospitalized than decedents of other racial and ethnic groups (1,3–5). Although cultural beliefs of racial and ethnic groups affect where people die, place of death is decided by a complex interplay of many factors, including individual preferences, social support, access to care, age at death, cause of death, and the services being used around the time of death.

Place of death varied by race and Hispanic origin in 2007. Among decedents 65 years of age and over, non-Hispanic white decedents were less likely to die while hospitalized and more likely to die in nursing homes than Hispanic or non-Hispanic black, American Indian or Alaska Native, or Asian or Pacific Islander decedents. Among decedents under age 65, non-Hispanic white decedents were more likely to die at home and less likely to die while hospitalized than the other racial and ethnic groups examined.

Figure 34 consists of two bar charts showing the place of death, for decedents under 65 years of age and those 65 years of age and over, by race and Hispanic origin, for 2007.

Figure 34Place of death, by age and race and Hispanic origin: United States, 2007

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NOTE: See data table for Figure 34.

SOURCE: CDC/NCHS, National Vital Statistics System.

References

1.
Weitzen S, Teno JM, Fennell M, Mor V. Factors associated with site of death: A national study of where people die. Med Care. 2003;41(2):323–35. [PubMed: 12555059]
2.
Hopp FP, Duffy SA. Racial variations in end-of-life care. J Am Geriatr Soc. 2000;48(6):658–63. [PubMed: 10855602]
3.
Grunier A, Mor V, Weitzen S, Truchil R, Teno J, Roy J. Where people die: A multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007;64(4):351–78. [PubMed: 17684107]
4.
Johnson KS, Kuchibhatala M, Sloane RJ, Tanis D, Galanos AN, Tulsky JA. Ethnic differences in the place of death of elderly hospice enrollees. J Am Geriatr Soc. 2005;53(12):2209–15. [PubMed: 16398911]
5.
Flory J, Yinong YX, Gurol I, Levinsky N, Ash A, Emanuel E. Place of death: U.S. trends since 1980. Health Aff (Millwood) 2004;23(3):194–200. [PubMed: 15160817]
6.
Duffy SA, Jackson FC, Schim SM, Ronis DL, Fowler KE. Racial/ethnic preferences, sex preferences, and perceived discrimination related to end-of-life care. J Am Geriatr Soc. 2006;54(1):150–7. [PubMed: 16420213]
7.
Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476–82. [PubMed: 11074777]

Intensive Care Unit (ICU) Days in the Last 6 Months of Life

The mean number of days Medicare decedents spent in an ICU during the last 6 months of life in 2005 varied from 1.3 days in North Dakota to 5.7 days in New Jersey.

A disproportionate percentage of health care dollars are spent in the last 6 months of life, and ICU stays are a significant portion of these health care costs. In the United States, 17% of deaths in 2001 followed a stay in the ICU, and 47% of hospital deaths were preceded by an ICU stay (1). In 2005, intensive and critical care medicine accounted for 13% of hospital costs and 4% of national health expenditures. Daily costs averaged $3,518, compared with daily average non-critical care costs of $1,153; total annual critical care medical costs were $81.7 billion in 2005 (2). Use of ICU/CCU care is determined by supply, provider practice patterns and preferences, patient preferences, and case mix or “need” (3,4).

The mean number of days that people spend in an ICU or a cardiac care unit in their last 6 months of life varied widely by state of residence in 2005. Medicare decedents who were residents of states in upper New England and the upper Midwest averaged fewer days in the ICU/CCU than the U.S. mean of 3.5 days. Decedents who were residents of 12 states averaged less than 2 days in an ICU/CCU: North Dakota, Vermont, Oregon, Idaho, Wisconsin, New Hampshire, Maine, Wyoming, Iowa, South Dakota, Minnesota, and Montana. Medicare decedents who were residents of four states (Texas, Illinois, Nevada, and California) averaged between 4 and 5 days in the ICU/CCU in their last 6 months of life. Decedents who were residents of New Jersey and Florida averaged more than 5 days in an ICU/CCU in their last 6 months of life.

Figure 35 is a map of the United States showing the average number of days in the intensive care unit or critical care unit for Medicare decedents in the last 6 months of life, by state of residence, for 2005.

Figure 35Average number of days in ICU/CCU for Medicare decedents in the last 6 months of life, by state of residence: United States, 2005

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NOTE: See data table for Figure 35.

SOURCE: Dartmouth Atlas of Health Care.

References

1.
Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med. 2009;180(9):875–80. [PubMed: 19713448]
2.
Halpern NA, Pastores SM. Critical care medicine in the United States 2000–2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65–71. [PubMed: 19730257]
3.
Fisher E, Goodman D, Skinner J, Bronner K. Health care spending, quality, and outcomes: More isn’t always better [online] Dartmouth Atlas Project Topic Brief. 2009. Available from: http://www​.dartmouthatlas​.org/downloads/reports​/Spending_Brief_022709.pdf.
4.
Barnato AE, Herndon MB, Anthony DL, Gallagher PM, Skinner JS, Bynum JP, Fisher ES. Are regional variations in end-of-life care intensity explained by patient preferences? A study of the U.S. Medicare population. Med Care. 2007;45(5):386–93. [PMC free article: PMC2147061] [PubMed: 17446824]

Advance Directives

Discharged hospice care patients were more likely to have advance directives than current nursing home and home health care patients 65 years of age and over.

Advance directives are legal documents that establish guidelines for what treatments patients wish to receive and not receive (including life-sustaining treatments or procedures such as cardiac resuscitation) and who will make treatment decisions for them if they are unable to communicate informed decisions (1–4). Many people—even those who are seriously or terminally ill—do not enact directives. The decision to have advance directives depends on individual preference, cultural and religious beliefs, and medical condition and prognosis (3).

Among persons 65 years of age and over, 92% of discharged hospice care patients had some form of advance directive on file, compared with 70% of nursing home and 35% of home health care patients. Non-Hispanic white nursing home and home health care patients were more likely to have directives than Hispanic and non-Hispanic black patients. Non-Hispanic white and Hispanic discharged hospice care patients were more likely to have some directive prepared than non-Hispanic black patients. Although the life expectancy of nursing home and home health care patients varies considerably, hospice care is generally available only to persons whom a physician has determined have less than 6 months to live.

Among the 92% of hospice care patients 65 years and over with some directive in place, the most common forms were do not resuscitate (84%), power of attorney (38%), living will (27%), health care proxy (17%), and comfort measures only (13%) directives (5).

Figure 36 is a bar chart showing the percentage of nursing home, home health care, and hospice care patients with advance directives, for adults 65 years of age and over, by race and Hispanic origin, for 2004 and 2007.

Figure 36Advance directives among adults 65 years of age and over, by type of care and race and Hispanic origin: United States, selected years

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* Estimates are considered unreliable. Data preceded by an asterisk have a relative standard error of 20%–30%.

NOTE: See data table for Figure 36.

SOURCE: CDC/NCHS, National Nursing Home Survey and National Home and Hospice Care Survey.

References

1.
Advance directives [online] National Cancer Institute Fact Sheet. 2000. Available from: http://www​.cancer.gov​/cancertopics/factsheet​/support/advance-directives.
2.
Gaeta S, Price KJ. End-of-life issues in critically ill cancer patients. Crit Care Clin. 2010;26(1):219–27. [PubMed: 19944283]
3.
Prendergast TJ. Advance care planning: Pitfalls, progress, promise. Crit Care Med. 2001;29(2 suppl):N34–N39. [PubMed: 11228571]
4.
Silveira MJ, Kim SYH, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–8. [PMC free article: PMC2880881] [PubMed: 20357283]
5.
CDC/NCHS. National Home and Hospice Care Survey [unpublished analysis].

Selected Characteristics of Discharged Hospice Care Patients

In 2007, discharged hospice care patients were predominantly 65 years of age and over and non-Hispanic white, and most received hospice care in their homes.

Hospice care involves the provision of palliative care and support services for persons with terminal illnesses (1,2). In 1983, Medicare introduced a hospice care program. Since 1985, the number of certified hospice care agencies has grown 20-fold (Table 119). Medicare’s hospice program covers an assortment of medical and support services, some of which are not covered by traditional Medicare. Covered services include spiritual, psychosocial, and family bereavement counseling; pain medications; homemaker services; and respite care (2–4). To be eligible for hospice care, Medicare and most other insurers require that a physician certify that the patient is expected to die within 6 months if their illness follows its anticipated course, and the patient must forego curative treatment. Recently passed health care reform legislation requires that Medicare study the impact of relaxing the requirement that hospice care patients forego curative treatment.

The vast majority of discharged hospice care patients in 2007 were 65 years of age and over, Medicare beneficiaries, and non-Hispanic white. Just over one-half were female. Two-fifths were widowed, 45% were married or living with a partner, and the remainder were single, divorced, or separated. Over one-half received hospice care while in their own homes, and another one-fifth received care in nursing homes. Most died while receiving hospice care, but 16% were discharged alive.

Figure 37 consists of six pie charts showing selected characteristics of discharged hospice care patients, for 2007.

Figure 37Selected characteristics of discharged hospice care patients: United States, 2007

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NOTE: See data table for Figure 37.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey.

References

1.
U.S. General Accounting Office (GAO) Report to the Congress by the Comptroller General of the United States. HRD–79–50. Washington, DC: GAO; 1979. Hospice care—A growing concept in the United States. Available from: http://archive​.gao.gov/f0302/108711.pdf.
2.
Medicare Payment Advisory Commission (MedPAC) Report to the Congress: New approaches in Medicare. Washington, DC: MedPAC; 2004. Hospice care in Medicare: Recent trends and a review of the issues. pp. 139–54. Available from: http://www​.medpac.gov​/documents/June04_Entire_Report.pdf.
3.
Iglehart JK. A new era of for-profit hospice care—The Medicare benefit. N Engl J Med. 2009;360(26):2701–3. [PubMed: 19553645]
4.
Huskamp HA, Stevenson DG, Chernew ME, Newhouse JP. A new Medicare end-of-life benefit for nursing home residents. Health Aff (Millwood) 2010;29(1):130–5. [PubMed: 20048371]

Primary Admission Diagnosis of Discharged Hospice Care Patients

The percentage of discharged hospice patients with a primary diagnosis of cancer declined by one-third from 1998 to 2007.

The first formal hospice care agency in the United States opened in 1971 (1). At that time, hospice care was almost exclusively for terminally ill cancer patients for whom curative treatment was no longer reasonable (1). The goal of hospice care was to provide end-of-life care, as well as support services for patients and their families (1,2). Medicare introduced a hospice care program in 1983 that covered some services not included in traditional Medicare (2,3). In the last decade, the use of Medicare’s hospice benefit has increased rapidly, due to increased knowledge and appreciation among providers and patients and Medicare’s promotion of this benefit (2).

In 1998, 65% of discharged hospice care patients had a primary admission diagnosis of cancer. In 2007, cancer remained the most common diagnosis but had declined to 43% of patients. Increasingly, persons with other diagnoses are using hospice care. The top five diagnoses in 2007 were cancer, Alzheimer’s disease and other dementia, heart disease, chronic lower respiratory diseases, and stroke.

The use of hospice care has almost doubled in the past decade, from 182 discharges per 100,000 population in 1998 to 348 in 2007 (4). Despite greater use of hospice, the majority of hospice care patients have short stays. Although the median length of stay among discharged hospice care patients was 17 days in 2007, length of stay varied greatly. About one-third had hospice care for a week or less, while almost one-fifth had hospice care for longer than 90 days (4).

Figure 38 consists of three pie charts showing the primary admission diagnosis of discharged hospice care patients, for 1998 and 2007.

Figure 38Primary admission diagnosis of discharged hospice care patients: United States, 1998 and 2007

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Notes: CLRD is chronic lower respiratory diseases. See data table for Figure 38.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey.

References

1.
U.S. General Accounting Office(GAO) Report to the Congress by the Comptroller General of the United States. HRD–79–50. Washington, DC: GAO; 1979. Hospice care— A growing concept in the United States. Available from: http://archive​.gao.gov/f0302/108711.pdf.
2.
Medicare Payment Advisory Commission (MedPAC) Report to the Congress: New approaches in Medicare. Washington, DC: MedPAC; 2004. Hospice care in Medicare: Recent trends and a review of the issues. pp. 139–54. Available from: http://www​.medpac.gov​/documents/June04_Entire_Report.pdf.
3.
Iglehart JK. A new era of for-profit hospice care—The Medicare benefit. N Engl J Med. 2009;360(26):2701–3. [PubMed: 19553645]
4.
CDC/NCHS. National Home and Hospice Care Survey [unpublished analysis].

Services to Hospice Care Patients’ Family Members or Friends

Bereavement, spiritual services, and medication management were the most common types of services offered or provided to hospice care patients’ family members or friends.

A critical function of hospice care is the provision of palliative care to those with a terminal prognosis of 6 months or less. According to the National Consensus Project for Quality Palliative Care (1), the goal of palliative care is to”prevent and relieve suffering and to support the best possible quality of life for patients and their families. . .”Palliative care services should be comprehensive in nature and may require the expertise of various types of providers, such as physicians, nurses, social workers, nutritionists, and clergy, in order to adequately assess and treat the complex needs of seriously ill patients and their families (1). In 2007, 84% of hospice care patients were Medicare beneficiaries (Figure 37), and from its inception the Medicare hospice benefit was designed to be broad in scope and include grief counseling, respite care, and other services for caregivers and family members (2). Caregiver stress and burnout are increasingly recognized areas of concern (3–5).

In 2007, bereavement services were offered or provided to 85% of hospice care patients’ family members or friends; spiritual services and medication management information were offered or provided to two-thirds of family members or friends. Information about activities of daily living, safety training, and equipment use were offered to one-half of family members or friends. Caregiver health and wellness services were offered or provided to one-quarter of family members or friends.

Figure 39 is a bar chart showing the type of services offered or provided to hospice care patients’ family members or friends, for 2007.

Figure 39Services offered or provided to hospice care patients’ family members or friends: United States, 2007

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NOTE: See data table for Figure 39.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey.

References

1.
National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. 2nd ed. Pittsburgh, PA: National Consensus Project; 2009. Available from: http://www​.nationalconsensusproject​.org/guideline.pdf.
2.
Centers for Medicare & Medicaid Services (CMS) Hospice payment system. Medicare Learning Network Payment System Fact Sheet. Baltimore, MD: CMS; 2009. Available from: http://www​.cms.gov/MLNProducts​/downloads/hospice_pay_sys_fs​.pdf.
3.
Ybema JF, Kuijer RG, Hagedoorn M, Buunk BP. Caregiver burnout among intimate partners of patients with a severe illness: An equity perspective. Pers Relat. 2002;9:73–88.
4.
DuBenske LL, Wen KY, Gustafson DH, Guarnaccia CA, Cleary JF, Dinauer SK, McTavish FM. Caregivers’ differing needs across key experiences of the advanced cancer disease trajectory. Palliat Support Care. 2008;6(3):265–72. [PMC free article: PMC3590014] [PubMed: 18662420]
5.
Harding R, Higginson IJ. What is the best way to help caregivers in cancer and palliative care? A systematic literature review of interventions and their effectiveness. Palliat Med. 2003;17(1):63–74. [PubMed: 12597468]

Hospice Care Patients’ Symptoms at the Last Hospice Visit Before Death

One-third of hospice care patients had pain near the time of their death.

Controlling pain and other distressing symptoms near the end of life is a major concern identified by hospice care patients and their family members and by hospice care personnel (1–4). Nearly 90% of hospice care patients in 2007 had their level of pain assessed at the time of their admission to hospice care services (5).

Recognition of the onset of the acute phase of dying is important in order to initiate appropriate symptom control measures such as medication use, and comfort measures such as positioning, distraction, and guided imagery (4,6). Many family members and some health care professionals express concern that prescription narcotic pain medications, such as morphine, may hasten death or lead to addiction (4,7). Several studies refute the fear of hastened death associated with prescription narcotics use (4). Prescription narcotics are safe and effective for the treatment of patients with moderate to severe pain, and their side effects can be managed effectively (6). Constipation is the most frequent side effect of narcotic drugs (7). While many dying patients can have their pain controlled with manageable side effects, others experience breakthrough pain (4,8).

Based on information from agency personnel who were familiar with the care received, as well as information in the medical record for patients who died while under hospice care, one-half of hospice care patients had difficulty breathing at the time of their last hospice visit, one-third had pain, one-quarter had restlessness, nearly one-quarter had anorexia, and one-tenth had constipation.

Figure 40 is a bar chart showing hospice care patients’ symptoms at the last hospice care visit before death, for 2007.

Figure 40Hospice care patients’ symptoms at the last hospice care visit before death: United States, 2007

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NOTE: See data table for Figure 40.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey.

References

1.
National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. 2nd ed. Pittsburgh, PA: National Consensus Project; 2009. Available from: http://www​.nationalconsensusproject​.org/guideline.pdf.
2.
Shugarman LR, Lorenz K, Lynn J. End-of-life care: An agenda for policy improvement. Clin Geriatr Med. 2005;21(1):255–72. [PubMed: 15639050]
3.
Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: Observations of patients, families, and providers. Ann Intern Med. 2000;132(10):825–32. [PubMed: 10819707]
4.
National Cancer Institute (NCI) Last days of life (PDQ): Symptom management. Bethesda, MD: NCI; 2010. Available from: http://www​.cancer.gov​/cancertopics/pdq/supportivecare​/lasthours​/HealthProfessional/page2.
5.
CDC/NCHS. National Home and Hospice Care Survey [unpublished analysis].
6.
Sykes N. End of life issues. Eur J Cancer. 2008;44(8):1157–62. [PubMed: 18374561]
7.
Leleszi JP, Lewandowski JG. Pain management in end-of-life care. J Am Osteopath Assoc. 2005. pp. S6–11. Available from: http://www​.jaoa.org/cgi​/content/full/105/3_suppl/6S. [PubMed: 18154192]
8.
Hanks GW, de Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al. Morphine and alternative opioids in cancer pain: The EAPC recommendations. Expert Working Group of the Research Network of the European Association for Palliative Care (EAPC) Br J Cancer. 2001. pp. 587–93. Available from: http://www​.ncbi.nlm.nih​.gov/pmc/articles​/PMC2363790/pdf/84-6691680a.pdf. [PMC free article: PMC2363790] [PubMed: 11237376]

Hospice Care Patients’ Drugs in the Last Week of Life

Ninety percent of hospice care patients had a narcotic analgesic (for severe pain) prescribed to them in the last week of life.

A fundamental goal of hospice care is the relief of pain and management of symptoms in those with a life expectancy of 6 months or less (1). Methods for pain and symptom relief can include relaxation techniques, imagery, distraction, skin stimulation, acupuncture, and over-the-counter and prescription medications (2). As the course of a terminal illness progresses, questions arise as to whether to continue to treat comorbid medical conditions with drugs or to only use drugs to manage symptoms related to dying (3,4).

In a national sample of hospice care providers, medication information was obtained from patients’ records and included drugs prescribed in the last 7 days of life. The most commonly prescribed medications were related to symptoms often present near the time of death (Figure 40). Ninety percent of hospice care patients had a narcotic analgesic for pain control prescribed to them in the last week of life. Three-quarters of hospice care patients had an antiemetic for vomiting, and one-half of patients had a laxative for constipation. One-third of hospice care patients had an antipsychotic drug to treat restlessness or agitation that may be present in the final phase of life. One-quarter of hospice care patients had an antidepressant drug prescribed for treatment of depression or pain. Seven percent of hospice care patients had a cholesterol-lowering (antihyperlipidemia) drug, and 3% of hospice care patients had baby aspirin or clopidogrel (Plavix) for clot prevention.

Figure 41 is a bar chart showing selected drugs prescribed to hospice care patients in the last week of life, for 2007.

Figure 41Selected drugs prescribed to hospice care patients in the last week of life: United States, 2007

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NOTE: See data table for Figure 41.

SOURCE: CDC/NCHS, National Home and Hospice Care Survey.

References

1.
Medicare Payment Advisory Commission (MedPAC) Report to the Congress: New approaches in Medicare. Washington, DC: MedPAC; 2004. Hospice care in Medicare: Recent trends and a review of the issues. pp. 139–54. Available from: http://www​.medpac.gov​/documents/June04_Entire_Report.pdf.
2.
Symptoms during a fatal illness [online] Merck Manuals Online Medical Library. 2007. Available from: http://www​.merck.com​/mmhe/sec01/ch008/ch008f.html.
3.
Tanvetyanon T, Choudhury AM. Physician practice in the discontinuation of statins among patients with advanced lung cancer. J Palliat Care. 2006;22(4):281–5. [PubMed: 17263055]
4.
Currow DC, Stevenson JP, Abernethy AP, Plummer J, Shelby-James TM. Prescribing in palliative care as death approaches. J Am Geriatr Soc. 2007;55(4):590–5. [PubMed: 17397439]