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EPIDEMIOLOGY

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CAUSES OF DEATH

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In 2015, 2,712,630 individuals died in the United States (Table 9-1). Approximately 73% of these deaths occurred in those aged >65 years. The epidemiology of death has changed significantly since 1900 and even since 1980. In 1900, heart disease caused ~8% of all deaths and cancer accounted for <4% of all deaths. In 1980, heart disease accounted for 38.2% of all deaths, cancer 20.9%, and cerebrovascular disease 8.6% of all deaths. By 2014, there had been a dramatic drop in deaths from cardiovascular and cerebrovascular diseases. In 2014, 23.4% of all deaths were from cardiovascular disease and just 5.1% from cerebrovascular disease. Deaths attributable to cancer, however, had increased to 22.5%. The proportions of deaths due to chronic lower respiratory disease, diabetes, Alzheimer’s, and suicides have also increased. Interestingly, in 2014, HIV/AIDS accounted for <0.26% of all U.S. deaths.

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Table Graphic Jump Location
TABLE 9-1Ten Leading Causes of Death in the United States and Britain
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This change in the epidemiology of death is also reflected in the costs of illness. In the United States, ~84% of all health care spending goes to patients with chronic illnesses, and ~12% of total personal health care spending—slightly <$400 billion in 2015—goes to the 0.83% of the population in the last year of their lives.

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In developed countries, an estimated ~70% of all deaths are preceded by a disease or condition, making it reasonable to plan for dying in the foreseeable future. Cancer has served as the paradigm for terminal care, but it is not the only type of illness with a recognizable and predictable terminal phase. Since heart failure, chronic obstructive pulmonary disease (COPD), chronic liver failure, dementia, and many other conditions have recognizable terminal phases, a systematic approach to end-of-life care should be part of all medical specialties. Many patients with illness-related suffering also can benefit from palliative care regardless of prognosis. Ideally, palliative care should be considered part of comprehensive care for all chronically ill patients. Reviews of the recent literature have found strong evidence that palliative care can be improved by coordination between caregivers, doctors, and patients for advance care planning, as well as dedicated teams of physicians, nurses, and other providers.

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SITE OF DEATH

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Where patients die varies by country (Table 9-2). In Belgium and Canada, for instance, over half of all cancer patients still die in the ...

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