How and Where Kiwis Die How and Where Kiwis Die

Deaths in New Zealand and the Need for Palliative Care Hospice NZ Conference October 2014

Overview Increasing Numbers of Deaths Deaths at Older ages Changing Ethnicity of Deaths Place of Death Cause of Death Challenges for Hospices Patterns of Need for Palliative Care Answering the other big questions …

Increasing Numbers of Deaths

Deaths in New Zealand 2000-2010 There has been remarkable stability in the total number of deaths since 2000, with perhaps only a very small increase. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Historic Deaths Hospice movement began in 1979 in New Zealand. Deaths increased slowly from some 25,000 a year to about 30,000 a year by 2011. Source: Palliative Care Council, Working Paper No. 1, July 2013 Drawn using data from Statistics New Zealand

Historic Deaths and Current Plans Previous planning horizon has been to 2026. Source: Palliative Care Council, Working Paper No. 1, July 2013 Drawn using data from Statistics New Zealand

Historic Deaths, Future Projections The escalation in the number of deaths is going to be substantial and it is thus important for future planning to look much further than 2026. Source: Palliative Care Council, Working Paper No. 1, July 2013 Drawn using data from Statistics New Zealand

Historic Births and Deaths 1876-2012 Baby Boomers are usually regarded as those born in the years 1946–65 Source: Statistics New Zealand data, 1876 to 2012

Age by Which Selected Percentage Have Died, by Birth Cohorts The great majority of survivorship improvements occurred at childhood and young adult ages. Source: Statistics New Zealand (2006). A History of Survival in New Zealand: Cohort life tables 1876–2004.

Crude Death Rates in New Zealand The crude death rate has declined historically. We are currently at a low point for the crude death rate and the rate is expected to rise by the 2050s to levels last seen in the 1940s and 1950s. This is NOT a failure of medicine! Source: Palliative Care Council, Working Paper No. 1, July 2013 Drawn using data from Statistics New Zealand

Deaths at Older Ages

Deaths in New Zealand 2000-2010 30.1% of all deaths are over age 85; 60.1% are over age 75 and 77.4% are over age 65. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Deaths in New Zealand 2000-2010 Note steady increase in deaths over age 85 over the period, from 25.9% of deaths in 2000 to 33.2% of deaths in 2010. Decline in deaths age 65-74. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Historic Deaths and Future Projections by Age Band Deaths will change in their distribution across age groups. Expected to be a continued decline in deaths under age 65 and age 65-74, with a dramatic increase in the number of deaths over age 85. Source: Palliative Care Council, Working Paper No. 1, July 2013. Drawn using data from Statistics New Zealand; personal communication Joanna Broad.

Deaths in New Zealand 2000-2010 All Causes 39.3% of all deaths for women are over age 85; men dying at younger ages and with more deaths under age 65 (26.9%). Source: Analysis of Ministry of Health MORT data 2000 to 2010

Trajectories at the End of Life Accidents Cancer Organ failure Frailty and dementia “Trajectory 1 is characterised by a short period of evident decline over a period of weeks or months. Good function may be maintained for some time, with a few weeks or months of rapid decline as the illness becomes overwhelming and leads to death. Generally there is time to anticipate needs and plan for end of life care. While many diseases follow this course, it is typical of the major cancers. This trajectory meshes well with traditional palliative care services that concentrate on providing comprehensive care over the last weeks or months of a person’s life. About 20 per cent of people will follow this trajectory.” “Trajectory 2 is characterised by long-term limitation of function with intermittent severe, acute episodes. Patients with heart failure or chronic obstructive pulmonary disease (COPD) are usually ill for many years. They frequently experience acute and often severe exacerbation of their physical symptoms. These exacerbations are frequently associated with admission to hospital and intensive treatment. If patients survive an episode, they may well return home without much progression of their everyday disabilities. Patients usually survive many such episodes but at some point, rescue attempts fail. The timing of death is often a surprise in this group, despite their long-term chronic illness. Although many illnesses can follow this course, chronic heart failure and emphysema are the most common. About 25 per cent of people will follow this trajectory.” Trajectory 3: Those who escape cancer and organ failure as they age will be likely to die of either dementia or generalised frailty. This trajectory is characterised by progressive disability from a baseline of already low cognitive or physical function. Gradual decline in functional capacity combined with the impact of often minor physical events—for example a fall or a respiratory or urinary infection—can prove fatal. Approximately 40 per cent of people will follow this trajectory.” “The three characteristic trajectories described above are roughly sequential in relation to the ages afflicted, with illness trajectory 1 (cancer) peaking around age 65, fatal chronic organ system failure (trajectory 2) about a decade later and frailty and dementia (trajectory 3) afflicting those who live past their mid-eighties.” [Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document. 2010. Canberra: Palliative Care Australia.] Diagram from Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. 2003. RAND Health. ] Source: Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document. 2010. Canberra: Palliative Care Australia. Diagram from Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. 2003. RAND Health.

Trajectories at the End of Life The three characteristic trajectories are roughly sequential in relation to the ages afflicted with cancer (trajectory 1) peaking around age 65 fatal chronic organ system failure (trajectory 2) about a decade later, and frailty and dementia (trajectory 3) afflicting those who live past their mid-eighties. Source: Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document. 2010. Canberra: Palliative Care Australia.

Implications of Older Deaths The major challenge for palliative care will be that not only will the number of deaths be increasing, but they will be increasing in older age bands. These deaths are likely to be occurring to people with more co-morbidities and a high prevalence of dementia. If current patterns of end-of-life care continue most of these deaths over age 85 will occur in residential aged care facilities after an extended period of care. Will challenge existing models of care. Will challenge the way end of life care is funded.

Changing Ethnicity of Deaths

Expected Population New Zealand FY 2014 Māori make up 15.3% of the population, with Other (non- Māori, non-Pacific, non-Asian) making up 65.8%. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health

Expected Births in New Zealand FY 2014 Māori make up 28.4% of births. Māori, Pacific and Asian together make up more than half of births, 52.8%. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health

Expected Deaths in New Zealand FY 2014 Māori make up 10.3% of deaths, with Other (non- Māori, non-Pacific, non-Asian) making up 82.9%. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health

Ethnicity New Zealand 2014 Significant bulge in the Asian population in the early working years. High proportion of children for Māori and Pacific. At oldest ages, predominantly Other (non- Māori, non-Pacific, non-Asian). Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health

New Zealand - Change in Deaths All ethnic groups increase. Deaths for Pacific increase slightly faster than for Māori. Asian deaths increase very much faster. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health

Caution … This analysis is based on population projections from Statistics New Zealand using Census 2006 as a base. Census 2013 has shown that the Asian population has been increasing at a particularly fast rate. During the seven-year period between censuses: Chinese – up 16% Indian – up 48% Filipino – more than doubled. We might therefore expect that the increase in the Asian population might lead to even higher numbers of future Asian deaths. Or will there be a “salmon bias” effect? New projections of the total population using Census 2013 as a base are expected in November 2014.

Cause of Death

Cause of Death 2000-2010 29.1 % of deaths are from neoplasms which includes malignant and benign neoplasms. 38.3% of deaths from circulatory system conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 On average, 28,292 deaths each year. Women account for 49.9% of deaths from all causes. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Women account for 49.9% of deaths from all causes. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Maternity, Perinatal and Congenital On average, 332 deaths from maternity, perinatal and congenital conditions each year (7 due to pregnancy and childbirth). Perinatal and congenital: girls and women are 44.9% of deaths; boys and men 55.1%. Deaths continue to oldest ages. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 External Causes On average, 1,781 deaths from external causes each year. Women account for 34.0% of deaths and men for 66.0%. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Neoplasms On average, 8,235 deaths from neoplasms each year. Women account for 47.3% of deaths and men for 52.7%. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Circulatory System On average, 10,823 deaths from circulatory system conditions each year. Women account for 52.2% of deaths and men for 47.8%. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Other Conditions On average, 7,121 deaths from other conditions each year. Women account for 53.7% of deaths and men for 46.3%. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Historic Cause of Death 2000-2010 In proportional terms, large decrease in deaths from circulatory system conditions, little change in deaths from neoplasms and large increase in deaths from other conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Deaths in New Zealand 2000-2010 Neoplasms The majority of deaths from neoplasms are between ages 65 and 84 with 50.9% for women and 60.4% for men. Proportionately more women than men die from neoplasms below age 65. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Deaths in New Zealand 2000-2010 Circulatory System 52.7% of circulatory system deaths for women are over age 85 compared to only 27.0% for men. Proportionately more men die below age 75 (37.9% for men and 16.9% for women). Source: Analysis of Ministry of Health MORT data 2000 to 2010

Deaths in New Zealand 2000-2010 Other Conditions More women than men over age 85 die of other conditions, 44.6% for women and 27.5% for men. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death

Place of Death 2000-2010 All Causes The largest proportion died in hospital (34.2%), followed by residential care (30.7%) and private residence (22.3%). Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 All Causes Very significant differences in place of death by gender. Proportionately more woman die in residential care (37.6% of women, 24.0% of men). More men die in a private residence (26.1%, compared to 18.4% for women). Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 All Causes Significant patterns by age and gender, with a distinct funnel of deaths in residential care as age increases. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 Neoplasms Later in life, residential care is a significant place of death from neoplasms. Hospital becomes a less likely place of death as age increases. Source: Analysis of Ministry of Health MORT data 2000 to 2010 Smoothing of the under 24 age bands where there is very little data.

Place of Death 2000-2010 Circulatory System Later in life, residential care is a significant place of death from circulatory system conditions. Hospital is a significant place of death until the older ages. Source: Analysis of Ministry of Health MORT data 2000 to 2010 Smoothing of the under 40 age bands where there is very little data.

Place of Death 2000-2010 Other Conditions Late in life, residential care is a very significant place of death from other conditions and more so for women than men. Source: Analysis of Ministry of Health MORT data 2000 to 2010 Smoothing of the under 40 age bands where there is very little data.

Place of Death 2000-2010 Overall, deaths in residential care accounted for 30.7%. Over time, an increasing proportion of deaths are in residential care, from 27.6% of deaths in 2000 to 32.3% of deaths in 2010. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 Male Hospital and private residence are most common places for male deaths. Deaths in residential care have increased over the period and now equal deaths in private residence. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 Female Residential care is most common place for female deaths, with private residence much smaller than residential care or hospital. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2000-2010 Age 85+ 30.1% of deaths occur at age 85 and over and residential care is the predominant place of death: 58.8% of women and 47.3% of men aged 85+. Some deaths in public hospital likely to be after transfer from residential care. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death by Place of Death

Cause of Death 2000-2010 All Settings 29.1 % of deaths are from neoplasms which includes malignant and benign neoplasms. 38.3% of deaths from circulatory system conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Hospital Fewer deaths from neoplasms than for country as a whole. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Residential Care Very similar pattern of causes to deaths in hospital, but lower external causes, perinatal and congenital. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Private Residence 29.1 % of deaths are from neoplasms which includes malignant and benign neoplasms. 38.3% of deaths from circulatory system conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Cause of Death 2000-2010 Hospice Inpatient Unit 89.7% of deaths are from neoplasms. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Challenges for Hospices

Place of Death 2000-2010 Neoplasms Marked increase in residential care as the place of death for those with neoplasms – by 2010 equivalent to deaths in hospital. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Questions … What proportion of people who die in New Zealand receive palliative care? Ideally by cause of death What proportion of people who die in New Zealand receive hospice care? Are we properly reflecting the extent and reach of hospice care?

Place of Death Hospice Patients 2012 24.4% of hospice patients died in a hospice in-patient unit. 33.9% died in a private residence and 24.9% in residential aged care. Hospice definitions used. Data source: Correspondence with Hospice NZ, March 2014.

Place of Death 2010 before Hospice Adjustment The patterns (not actual data) from the hospice benchmarking data in 2012 have been applied by indexing the deaths of clients in other settings to deaths in hospice inpatient units. The patterns were then applied to this MORT data. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Place of Death 2010 after Hospice Adjustment The patterns (not actual data) from the hospice benchmarking data in 2012 have been applied by indexing the deaths of clients in other settings to deaths in hospice inpatient units. The patterns were then applied to this MORT data. Source: Analysis of Ministry of Health MORT data 2000 to 2010; with data from Hospice NZ

Initial Answers The estimates suggest that hospice clients could be 26.6% of total deaths in 2010 rather than the 6.5% of total deaths in hospice inpatient units as initially shown. The estimates suggest that hospice clients are: 12.6% of hospital deaths 20.5% of residential care deaths 40.2% of deaths that occur in a private residence. Figures will be higher if external causes of death not included. These figures may still underestimate hospice involvement with residential care. In recent years individual hospices have had extensive outreach programmes to the staff in aged residential care facilities and to district nursing teams.

Work to be done … Much work remains to be done in order to characterise hospice contact across all settings. Prof Rod McLeod said: “Variability [of] amount of service is another challenge. Do you count a telephone call once a week as providing care? i.e. does any contact constitute service delivery.” The collection of meaningful data about different forms of care and support by hospice will be a challenge for all hospices in the years ahead. Start by describing the packages of care offered in different settings.

Example of Packages of Care What packages of interaction do you have? In-patient hospice care Community care at home provided by hospice staff Community care in aged residential care? Support to aged residential care facilities? Levels of that support? Support in/to hospitals? … We need to define these in order to measure the full contribution hospice makes to end of life care in New Zealand.

Patterns of Need for Palliative Care

Health Needs Assessment Phase 1 Phase 1: Assessment of Palliative Care Need It established, for the first time, the number of people who might benefit from palliative care in New Zealand. Used MORT data from 2005-2007. Report prepared by Wayne Naylor

Previous Estimate of Need for Palliative Care In 2006, 27 909 deaths in total, with 15 725 (56.3%) amenable to palliative care (mid-range estimate). Minimal estimate for adults: 41.8% of deaths amenable to palliative care. Source: Health Needs Assessment Phase 1 Report

Methodology and New Papers Australia: Rosenwax (2005) and McNamara (2006). Was the basis for adults in the HNA Phase 1 report UK: Cochrane (2007) for children and young people Was the basis for under 20s in the HNA Phase 1 report UK: Murtagh (2013) Compared Rosenwax, Higginson and Gómez-Batiste, then developed revised approach. Produced much higher estimates. England and Wales: Hain (2013) New Paediatric Directory of Life-Limiting Conditions More extensive than Cochrane World: WPCA and WHO Global Atlas (2014) Uses early Higginson approach, with updated assumptions Spain: Gómez-Batiste (2014) Testing tools for identification of palliative care need.

Need for Palliative Care 2000-2010 Original Estimate (HNA1, 2011) First New Zealand estimate, using Rosenwax (2005) and McNamara (2006) as primary sources. Cochrane (2007) used for under age 20. Concerned it underestimates palliative care need at older ages. Preliminary Results: do not quote without speaking to author Data Source: Analysis of Ministry of Health MORT data 2000 to 2010

Need for Palliative Care 2000-2010 Murtagh (2013), Cochrane (2007) Uses new Murtagh et al (2013) methodology, with Cochrane (2007) for under age 20. Produces results for Minimal estimate which are roughly double the original New Zealand methodology. Preliminary Results: do not quote without speaking to author Data Source: Analysis of Ministry of Health MORT data 2000 to 2010

Need for Palliative Care 2000-2010 Comparison of major methods. Preliminary list of conditions for revised NZ Minimal estimate. But still has poor shape at older ages. Preliminary Results: do not quote without speaking to author Data Source: Analysis of Ministry of Health MORT data 2000 to 2010

Need for Palliative Care 2000-2010 Initial thoughts on potential impact of adding all deaths in residential care over age 65. See also approach for adding residential care by Gómez-Batiste (2012). Preliminary Results: do not quote without speaking to author Data Source: Analysis of Ministry of Health MORT data 2000 to 2010

Next Steps … Now ready to have conversations with a clinical panel. Will need to draw up a list of conditions that might be amenable to palliative care, taking into account revisions in methodology world-wide. Adapt to New Zealand conditions and data. Finalise patterns of historic need for palliative care. Apply patterns to new projections of the population from Statistics New Zealand Based on Census 2013 not Census 2006. Expect final report mid-2015.

Answering the other big questions …

Overview Projects Planned 2014-16 Consensus on Minimum Standards for Last Days of Life for all New Zealanders Palliative Care in Aged Residential Care Palliative Care in Primary Care Palliative Care Glossary National Health Needs Assessment for Palliative Care – Phase 1 – Need National Health Needs Assessment for Palliative Care – Phase 2 – Capability Palliative Care Research Register Costing of Palliative Care and End of Life Care As at October 2014

Projects Planned 2014-16 Palliative Care in Aged Residential Care Increase in numbers and age of deaths – released as WP No. 1 Background paper – released as WP No. 2 Patterns of deaths by age, gender, diagnosis, place of death – in preparation as WP No. 8 Paper on contracts, nature of sector and increasing frailty of residents - in preparation as Working Paper No. 9 Definition of palliative care in aged residential care. In progress as part of glossary revision and discussion paper. Compare standards across hospice and ARC, as well as Australian standards in ARC and GSF for aged care. Projection of future need for palliative care in ARC. Working within MOH, with Hospice NZ and with ARC sector on understanding palliative care in this setting. As at October 2014

Projects Planned 2014-16 National Health Needs Assessment for Palliative Care – Phase 1 – Need Deaths in New Zealand: History and Projections. WP No. 1 Deaths in New Zealand: Regional and Ethnic Projections, 2014-2026. WP No. 3 Deaths in New Zealand: Place of Death 2000-2010. WP No. 4 Cancer Deaths in New Zealand, 2000 to 2010. WP No. 6 Deaths in Residential Care in New Zealand: 2000-2010. WP No. 8 Paediatric Deaths in New Zealand, 2000 to 2010. In progress Patterns of Need for Palliative Care: 2000-2010. In progress Final report when new national population projections are released by Statistics New Zealand (PCC report in mid-2015) As at October 2014

Projects Planned 2014-16 Costing of Palliative Care and End of Life Care The major strategic challenge for palliative care is that annual deaths are expected to almost double by 2061 and will increasingly be in older age bands (age 85+). These deaths are likely to be occurring to people with more co-morbidities and a high prevalence of dementia. This is likely to challenge both existing models of care and the way end-of-life care is funded.   A programme of research has begun with the BODE3 programme at the University of Otago, Wellington. The plan is to gather evidence of the cost of end-of-life and palliative care, according to trajectories at the end of life. As at October 2014

High Costs at the End of Life ? Will be working with hospices and aged residential care to improve information and costings at the end of life. Preliminary, unpublished results July 2014

Trajectories at the End of Life Accidents Cancer Organ failure Frailty and dementia “Trajectory 1 is characterised by a short period of evident decline over a period of weeks or months. Good function may be maintained for some time, with a few weeks or months of rapid decline as the illness becomes overwhelming and leads to death. Generally there is time to anticipate needs and plan for end of life care. While many diseases follow this course, it is typical of the major cancers. This trajectory meshes well with traditional palliative care services that concentrate on providing comprehensive care over the last weeks or months of a person’s life. About 20 per cent of people will follow this trajectory.” “Trajectory 2 is characterised by long-term limitation of function with intermittent severe, acute episodes. Patients with heart failure or chronic obstructive pulmonary disease (COPD) are usually ill for many years. They frequently experience acute and often severe exacerbation of their physical symptoms. These exacerbations are frequently associated with admission to hospital and intensive treatment. If patients survive an episode, they may well return home without much progression of their everyday disabilities. Patients usually survive many such episodes but at some point, rescue attempts fail. The timing of death is often a surprise in this group, despite their long-term chronic illness. Although many illnesses can follow this course, chronic heart failure and emphysema are the most common. About 25 per cent of people will follow this trajectory.” Trajectory 3: Those who escape cancer and organ failure as they age will be likely to die of either dementia or generalised frailty. This trajectory is characterised by progressive disability from a baseline of already low cognitive or physical function. Gradual decline in functional capacity combined with the impact of often minor physical events—for example a fall or a respiratory or urinary infection—can prove fatal. Approximately 40 per cent of people will follow this trajectory.” “The three characteristic trajectories described above are roughly sequential in relation to the ages afflicted, with illness trajectory 1 (cancer) peaking around age 65, fatal chronic organ system failure (trajectory 2) about a decade later and frailty and dementia (trajectory 3) afflicting those who live past their mid-eighties.” [Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document. 2010. Canberra: Palliative Care Australia.] Diagram from Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. 2003. RAND Health. ] Source: Palliative Care Australia (2010). Health System Reform and Care at the End of Life: a Guidance Document. 2010. Canberra: Palliative Care Australia. Diagram from Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. 2003. RAND Health.

Historic Cause of Death 2000-2010 Over this time period, large decrease in deaths from circulatory system conditions, small increase in deaths from neoplasms with larger increase in deaths from other conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010

Historic Deaths 1948 to 2010 Source: Analysis of Ministry of Health data: “Mortality: Historical summary 1948–2010”, published online May 2014. Definitions not identical to causes of death categories in MORT 2000 to 2010 analysis.

Consequences of Increased Longevity? Consequences of success of the health system in increasing longevity. Or in other words, delaying deaths. Evidence that cause of death has changed over time. How is it likely to change in the future? Are we increasingly likely to have longer periods of decline at the end of life? More frailty and dementia? What does this mean for palliative care? What settings of care will we need? What does it mean for formal and informal caregivers? How will we fund the care needed?

Future Births, Future Deaths The “Baby Boomers” changed births and maternity: natural birth, midwives. We expect them to change dying and palliative care: natural death and acting as midwives to the Soul. Source: data from Statistics New Zealand, using Census 2006 base.

Prof Heather McLeod Senior Analyst, Palliative Care Cancer Control New Zealand Office of the Chief Medical Officer Ministry of Health www.cancercontrolnz.govt.nz/palliative-care Email: Heather_McLeod@MOH.govt.nz MOH office: 04 819-6846 UOW office: 04 918-5516 Mobile: 0210 279-7425