programs that encourage communication about people's goals and preferences as they approach death.

The twenty-first century will bring new realities as well as continuing problems and opportunities in care at the end of life. It will undoubtedly deliver improvements in what medical science can do to prevent and relieve distress for those approaching death, but demographic, economic, and other trends will strain systems that already find it difficult to deliver what clinical knowledge currently allows—and what compassion should grant.

The next century will see the final demographic consequences of the post-World War II baby boom. The oldest members of the baby boom generation will reach age 65 in the year 2011, and the youngest members will do so nearly 20 years later. The elderly will constitute a larger proportion of the population than today, and the absolute numbers of dying patients will be substantially higher. Although health care and social service providers have a long lead time compared with the educators and communities who had to scramble to provide schooling for the baby boom generation, the difficulties that policymakers are already having with Social Security and Medicare do not bode well for the nation's ability to cope with the social, medical, economic, and other effects of an aging population.

Contrary to some popular thinking, however, the increase in overall personal health care spending is not explained by disproportionate growth in costs for end-of-life care. The small percentage of people who die each year do account for a significant proportion of health care expenditures, but the share of spending accounted for by this group does not appear to have changed much since the 1970s. Overall, increased health care spending is primarily accounted for by population growth, general inflation in the economy, and additional medical care inflation. One reason for the attention to the cost of care at the end of life is that such care is, in considerable measure, funded through Medicare, Medicaid, veterans, and other public programs.

Pressures to control public and private health care costs will continue and, indeed, will likely intensify with consequent restructuring of how health care is organized, delivered, and financed. More older people with advanced disease will be served by different kinds of managed care organizations. If effective quality monitoring and improvement methods are in place, the strengths and limitations of these varied arrangements will become clearer as their experience with end-of-life care grows. Possible problem areas include contracting, payment, and review mechanisms that limit access to clinicians and care teams experienced in palliative care; patient scheduling norms that limit time for careful patient-clinician communication; and marketing strategies that may discourage enrollment by seriously ill people.



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