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June 19, 2017

SUMMARY

Anesthesiologists and nurse anesthetists treat a significant proportion of patients over the age of 65. It behooves anesthesia groups to understand the needs of this significant population as they relate to aging and end-of-life medical care. Toward this end, we present a summary of a recent attitudes survey on these issues conducted by the Kaiser Family Foundation with The Economist.

U.S. Census Bureau projections indicate that Americans 65 and older will make up 24 percent of the U.S. population by 2060.  A majority of adults in the U.S. say that the government is “not too prepared” or “not at all prepared” to deal with the aging population, according to a recent survey conducted by the Kaiser Family Foundation in partnership with The Economist.  This study covered views and experiences related to aging and end-of-life medical care in the U.S., Italy, Japan and Brazil, among a nationally representative sample of adults ages 18 and older.

For anesthesiologists, nurse anesthetists, other healthcare professionals and facilities serving those in the later stages of life, this study has important long-term planning implications and highlights an opportunity and responsibility to serve a rapidly aging population.  An analysis of data conducted for this eAlert on Medicare patients treated by a representative sample of ABC clients in eight states in 2015 and 2016 reveals a range of patients over the age of 65 of 29 to 42 percent.  Clearly, attitudes about aging and end-of-life care are issues that need to be on every anesthesia group’s radar.

The Kaiser study covers a wide range of issues, starting with financial responsibility.  Americans are fairly evenly divided between those who believe individuals and families should bear the greatest responsibility for paying for people’s healthcare and long-term care needs as they age and those who place this responsibility on the government.  This stands in sharp contrast to the other countries surveyed, where majorities place the responsibility squarely on the government.

Aside from having financial responsibility, families are seen as having a major role to play in helping older adults.  A large majority (87 percent) believe that patients and their families should have the greater say in which treatment options to pursue for patients who are seriously ill and nearing the end of life, while just eight percent believe doctors should have the greater say.

Three-quarters of Americans say it is the duty of children to help take care of their parents’ needs as they get older, although older adults themselves are somewhat less likely to feel this way compared with younger Americans.  However, about half believe most people in the U.S. have too little control over decisions about their own medical care at the end of life, while about 40 percent feel patients have about the right amount of control. 

Americans also prefer honesty from their healthcare providers, no matter what the prognosis.  Of those surveyed, 88 percent say it is most important for doctors to be completely honest even if there is little chance of recovery.  Only seven percent say that when a patient is seriously ill, it is more important for their doctors to emphasize hope.

Seven in ten Americans believe that helping people die without pain, discomfort and stress is most important when it comes to healthcare at the end of people’s lives, while 20 percent believe that preventing death and extending life as long as possible is most important.  About 40 percent say the system places too little emphasis on helping people die without pain, discomfort and stress, and 20 percent say it places too little emphasis on extending life, while another 20 percent say it places too much emphasis on extending life.

Just over half of Americans say that making sure their family is not burdened financially by their care is extremely important in thinking about their own death.  About half also say making sure their wishes for medical care are followed, having loved ones around them, and being at peace spiritually are extremely important.  About four in 10 also say the same about making sure their family is not burdened by tough decisions about their care and being comfortable and without pain.  At the bottom of the list, 23 percent say that living as long as possible is extremely important to them.

As other research has shown, most Americans (71 percent) say that given the choice, they would prefer to die at home, with few saying they would choose a hospital, hospice or nursing home.  However, many do not expect their preferences to be the reality.  About 40 percent think they are most likely to die at home, while 24 percent expect to die in a hospital, six percent in a hospice, four percent in a nursing home, and 17 percent say they aren’t sure.

A majority in the U.S. and the other countries surveyed say death is a subject that is generally avoided; however, over half of U.S. adults say they’ve had a serious conversation with a spouse, parent, child or other loved one about their own wishes for end-of-life medical care.  In contrast, only 22 percent of those ages 65 and over say they’ve ever had such a conversation with a doctor or other healthcare provider, while about a third (over all age groups) say they’ve participated in a discussion with a doctor or other healthcare provider about another family member’s wishes for their care at the end of life.  

In addition to discussions with healthcare providers about one’s wishes for end-of-life medical care, another component of “advance care planning” is writing one’s wishes into a document, sometimes referred to as an “advance directive.”  Overall, about a quarter of U.S. adults say they have their end-of-life wishes for medical treatment in a written document.  Among the 72 percent who do not have their wishes written down, the most common reason is not having gotten around to it (49 percent), followed by never having considered it (27 percent).  Few say they’re worried they might change their mind about what they want or that they don’t think it will be useful.

Among those who experienced the death of a close friend or family member in the past five years, most family members who were involved in making medical decisions for a loved one feel that they had a good understanding of their loved one’s wishes for end-of-life treatment.  Furthermore, about three-quarters of this group report that they have participated in a discussion with a doctor or other healthcare provider about another family member’s wishes for end-of-life medical care, a much higher share than among the public at large.

Anticipating and meeting the needs of a rapidly aging population should be part of strategic planning discussions for all anesthesia groups and their facilities that serve patients in the later stages of life.  Our data indicate this population is significant for a representative sampling of ABC clients.  These numbers are likely to reflect many other anesthesia practices as well.  This is a time of great opportunity and responsibility for hospitals to facilitate end-of-life discussions with individuals and families during a very stressful time, and provide the information they need to make informed medical and financial decisions.

With best wishes,

Tony Mira
President and CEO