Dignity and Dying at Much Older Ages
By Heather McLeod
I am an actuary by training and my professional work is in health economics, health policy and social security policy. Although I work with the numbers daily, even I am taken aback when I look at the projections for the number of deaths and the age at which deaths will occur in years to come. There are huge implications for our society and our ability to provide compassionate and dignified care at the end of life.
There are two main forces at work: the first is the large increase in the total numbers of deaths in the future. Deaths in New Zealand are currently about 30,000 a year, while births fluctuate around 60,000 a year. Historically, births in New Zealand were at 30,000 a year after the First World War but the “Baby Boom” took us to over 60,000 births a year in the short period between 1946 and 1965. The leading edge of “boomers” are now beginning to enter the later years of their lives and so, over time, the number of deaths will catch up. Statistics NZ projects1 that deaths will increase by some 50 percent between 2016 and 2038, to a level of 45,000 a year in only 22 years. The increases will continue into the 2060s when deaths are projected to peak at over 58,000 a year, nearly a doubling from current levels.
The second force is, perhaps ironically, due to the success of our health system. People are increasingly dying at older ages and this trend is noticeable even over short periods of time. In the year 2000, deaths at age 85 and over were 26 percent of total deaths and by 2013 this had increased to more than 35 percent of total deaths2. The projections (again from Statistics NZ) are that by 2038, 56 percent of total deaths in New Zealand will be in the age group over 85 years.
The nature of deaths will also change. Palliative Care Australia3 refers to the sequential changes in cause of death, with cancer deaths peaking around age 65, deaths from chronic organ failure around age 75 and deaths from dementia and frailty for those who survive to 85 and beyond.
Researchers at the University of Bath Centre for Death & Society describe the nature of death at the oldest ages, saying4: “you will be very frail, possibly doubly incontinent, your sight, your taste, your hearing, your ability to orient yourself in time and space may all be severely compromised. You may be experiencing a lot of physical as well as emotional pain.” In New Zealand we project that the proportion needing palliative care will increase from about 80 percent in 2016 to nearly 83 percent of all deaths by 20382.
In the late Middle Ages, the “ars moriendi” ("The Art of Dying") were texts for society on how to approach death. Tony Walters, of the University of Bath5, describes how hospices developed the vision of the “ars moriendi” for the 20thand 21st centuries, saying “This movement has helped countless 50 and 60 year olds dying of cancer.” But with more deaths expected at much older ages and with deaths occurring gradually over a longer period, the challenge now is “how to add life to years when you are 90 and frail and have dementia.”
The place of death is also changing. Already, by 2013, for those over 85 years, 59 percent of women and 48 percent of men died in residential care2. If the patterns of the past continue, then with deaths occurring at much older ages it is projected that the number of deaths in residential care will increase from 10,400 a year in 2016 to 19,200 a year by 2038, an increase of nearly 85 percent. However, warnings have been issued that we are not providing enough facilities for caring for increased numbers of elderly and frail people6.
The revised national health strategy for New Zealand, released in 20167, is silent about these issues. Death barely features in that document. A key feature of the strategy is the idea that care will be provided closer to home but the burden on elderly carers of more deaths from frailty and dementia is not addressed.
The world is entering an unprecedented period with a much older population and fewer people of working age to fund the health and social care that will be needed. There are likely to be tough discussions as to how society will prioritise, pay for and organise care. In New Zealand, these discussions need to happen sooner and collectively, rather than be at the mercy of election cycles. Bioethics centres, such as The Nathaniel Centre, are well-placed to catalyse the dialogue that is much needed by society.
That’s at the macro level. But the more important issue is the impact on people. What do deaths at much older ages mean for our society? What do they mean for our communities? Most importantly, what do they mean for carers who will be increasingly elderly themselves? And do we understand what dignity means in the long, slow trajectories of dying with frailty and dementia?
I frankly don’t know the answers, but I hope that by sharing what we think is coming it will catalyse communities to take death back from the secularisation and medicalisation it has undergone in recent years. Churches potentially have a large role to play in shaping a new “ars moriendi” that is faithful to their understanding of human dignity informed by their philosophical and theological traditions
The Catholic Church of England and Wales has created a website, http://www.artofdyingwell.org/about-this-site/ that explores for today what was traditionally called the art of dying well, “ars moriendi”.
1. Statistics New Zealand. National Population Projections: 2016(base)–2068; 2016. URL: http://www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/NationalPopulationProjections_HOTP2016.aspx
2. McLeod H. The Need for Palliative Care in New Zealand. Technical Report prepared for the Ministry of Health, June 2016; 2016:103. URL: http://centraltas.co.nz/assets/Health-of-Older-People/Technical-Report-Need-for-Palliative-Care-vF2-June-2016-H-McLeod.pdf
3. Palliative Care Australia. Health System Reform and Care at the End of Life: a Guidance Document. Deakin West, ACT: Palliative Care Australia; 2010:96. URL: www.palliativecare.org.au/Portals/46/Policy/Health%20system%20reform%20-%20guidance%20document%20-%20web%20version.pdf
4. Kralova J. “Living longer”, is that good news? : University of Bath, G4 Dying Well Network; 2015 URL: https://gw4dyingwell.wordpress.com/2015/07/31/living-longer-kralova/GW4
5. Walter T. The Revival of Death: two decades on – by Tony Walter: University of Glasgow, End of Life Studies; 2015 URL: http://endoflifestudies.academicblogs.co.uk/the-revival-of-death-two-decades-on-by-tony-walter/
6. Westpac Institutional Bank. Industry Insights: Healthcare & Social Support Services; 2016. URL: https://www.westpac.co.nz/assets/Business/Economic-Updates/2016/Bulletins-2016/Industry-Insights-Healthcare-and-Social-Support-Services-October-2016.pdf
7. Ministry of Health. New Zealand Health Strategy: Future direction. Wellington: Ministry of Health; 2016. URL: http://www.health.govt.nz/publication/new-zealand-health-strategy-2016