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Palliative Care Perspectives : Chapter 1: Death and Dying in Modern Times : The Future

Prophecy is a dangerous but necessary business in medicine. What is the prognosis for palliative care over the next several decades? The only thing I can predict with certainty is that we will be surprised. The rapid evolution of palliative care in the past few years is a hopeful sign that we may be able to adapt to the broader societal changes underway in how we age, experience illness, and die. Here, I will tease out of an uncertain future one facet that I believe is relatively clear barring even more radical and unforeseen developments - a significant increase in the numbers of elderly and chronically ill individuals.

Baby boomers are getting old. The year 2010 will see the beginning of a rapid increase in the number of Americans over age 65. In the span of a mere 30 years, by 2030, the number of Americans over age 65 will double from approximately 35 to 70 million.28 Boomers tended to have fewer children than did their parents. Thus, we can safely predict that not only will there be more elderly people, there will be proportionately fewer younger workers and caregivers to support them. In 1940, when Social Security was first formed in the United States, 41 workers supported one benefit recipient. In 1998 the ratio was 3.4:1, and in 2030 the ratio will be 2.1:1.29 (I am indebted to Ira Byock, who kindly shared these references with me.)

This phenomenon is not isolated to the United States. A recent UN conference estimated that the number of people over age 60 will triple in the coming 50 years to 2 billion, approximately one-third of the world population. As birth rates fall, the numbers of younger people available to work and care for these elders will decrease. Currently, worldwide the proportion of working-age people to retirees is estimated to be 9:1. In 50 years it will be 4:1. In areas strongly affected by the AIDS epidemic such as Africa and Southeast Asia, it is the working-age adults and their children who are being stricken. They are often cared for by working grandparents.30 When these grandparents become too frail to work, who will care for them? The smaller pool of young and healthy workers will have to dedicate a greater percentage of their labor to the care of the older generation. To the children of my generation I can only say, "Work hard; we are going to need all the help we can get."

We can also reasonably predict that for those chronically ill elders in need of significant personal care, there will be fewer family members available to provide it. In part this will result from boomers having fewer children. Our children are more likely to live at a distance than was so in past generations. In most countries women, who historically have disproportionately provided such care, are more likely to be employed and less likely to be willing or able to quit their jobs to care for a sick parent, parent-in-law, or spouse.31,32

For the chronically ill who wish to live and die at home, when family members are unavailable to provide such care, the prospect of being able to hire professional aides also appears grim. Already, well before the boomer glut of the aging, there is a shortage of home health workers in America. This work ranks low on the social ladder, with wages just barely above minimum wage, and attracts the disadvantaged-often poorly educated, immigrant, and minority workers. Barring some dramatic change in how this work is publicly reimbursed, which seems unlikely in the short run, severe shortages of home health workers appear inevitable. The provision of care for chronically ill persons will increasingly be a privilege of the rich, who will have to pay large out-of-pocket sums to attract a small pool of workers.

If this prediction is correct, then, contrary to the hopes of many, fewer chronically ill people will be able to receive the care necessary for living at home. Inevitably, this will shift more people into institutional settings. It has been estimated that the number of Americans living in nursing homes will climb from 1.3 million currently to 5.3 million by 2030.7 If this occurs, a great challenge will be to reform existing institutions such as nursing homes and to create new institutions wherein we can deliver and receive humane care, including good palliative care.

While the above prediction (sadly) seems relatively safe to me, fundamental changes in how we age and become ill could change this situation. Although immortality is unlikely, at least in my lifetime, it does seem possible that recent medical developments may significantly affect the common courses of illnesses. Cancers might be cured. Alzheimer's disease might become preventable and treatable. It even seems possible that we will be able to slow the aging process in fundamental ways. If such changes come to pass, it is possible that fewer elders will need financial or personal support for long periods during old age. We can imagine that elders might remain very healthy into advanced old age until they undergo a rapid deterioration in health (a compression of morbidity into a shorter time span) or they choose to die33,34

While this seems theoretically possible, history would argue against this scenario; fixing one problem tends to create others. Thus, it would seem dangerously nave to believe that medical advances over the next 20 to 30 years will somehow save us from the demographic challenges we face. Assuming we will not be "saved" by a new biomedical revolution, if we do not at least make significant improvements in our health care system to accommodate the growing number of chronically ill, elderly, and dying people, we face disaster. There simply will not be enough nursing home beds, enough workers, or enough money to provide even the most basic care for those who will need it.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.