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Our society is facing one of the largest public health challenges in its history—the growth of the population of older adults. Improvements in public health, the discovery of antibiotics, and advances in modern medicine have resulted in unprecedented gains in human longevity. For most Americans, the years after the age of 65 are a time of good health, independence, and integration of one's life's work and experience. Eventually, however, most adults will develop one or more chronic illnesses with which they may live for many years before they die. More than three-quarters of deaths in the United States result from chronic diseases of the heart, lungs, brain, and other vital organs. Even cancer, which accounts for nearly a quarter of U.S. deaths, has become a chronic, multiyear illness for many. For a minority of patients with serious illness (e.g., metastatic colon cancer), the time following diagnosis is characterized by a stable period of relatively good functional and cognitive performance, followed by a predictable and short period of functional and clinical decline. However, for most patients with advanced illness (e.g., heart or lung disease, dementia, stroke, neuromuscular degenerative diseases, and many cancers), the time following diagnosis is characterized by months to years of physical and psychological symptom distress, progressive functional dependence and frailty, considerable family support needs, and high health care resource use. Indeed, as the population continues to age, most physicians will be caring for chronically ill individuals whose medical care is characterized by high degrees of complexity, lengthy duration of illness, and intermittent acute exacerbations interspersed with periods of relative stability. Abundant evidence suggests that the advanced stages of disease for most are characterized by inadequately treated physical distress; fragmented care systems; poor communication between physicians, patients, and families; and enormous strains on family caregiver and support systems.


Whereas a century ago, most adults died suddenly as a result of an acute infection or accident, the leading causes of death today are chronic illness such as heart disease, cancer, stroke, and dementia. Accompanying this shift in the causes of death has been a corresponding change in the location of death. Whereas in the early part of the 20th century, most persons died at home, today, most Americans will die in an institution (57% in hospitals and 17% in nursing homes). The reasons for this shift in location of death are complex but appear to be related to health system and reimbursement structures that promote hospital-based care and provide relatively little support for needed home care and custodial care services. Whereas the majority of Americans will die in an institution, these statistics hide the fact that most of an older person's last months and years are still spent at home in the care of family members, with hospitalization and/or nursing home placement occurring only near the very end of life. National statistics also obscure the variability in the experience of dying. For example, need for institutionalization or paid formal caregiving in the last months ...

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