1. Deaths in New Zealand: History, Projections and Challenges for Palliative Care Genesis Lecture Series 5 June 2014 1

2. 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 2

3. The great majority of survivorship improvements occurred at childhood and young adult ages. Age by Which Selected Percentage Have Died, by Birth Cohorts Source: Statistics New Zealand (2006). A History of Survival in New Zealand: Cohort life tables 1876–2004. 3

4. 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 4

5. 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. 5

6. Trajectories at the End of Life Accidents Cancer Organ failure Frailty and dementia 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. 6

7. 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. 7

8. Total Deaths 1948 to 2010 Source: Analysis of Ministry of Health data: “Mortality: Historical summary 1948–2010”, published online May 2014. 8

9. 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. 9

10. Regional and Ethnic Projections 2014 to 2026 February 2014 10

11. Projections of Population, Births and Deaths: 2014 to 2026 Prepared annually by Statistics New Zealand, using assumptions specified by the Ministry of Health. Usually available from late October. Projections by prioritised ethnicity: Māori, Pacific, Asian, Other Source: Palliative Care Council, Working Paper No. 1, July 2013. Period of projections 2014 to 2026 11

12. New Zealand Population 2014 The population has a relatively flat structure from childhood to age 55, with a steep decline in numbers thereafter. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health 12

13. Major differences between ethnic groups. Māori and Pacific have high proportion in childhood and young adult years. Asian very high in early working years. Other highest from age 45, with many more elderly. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health Standardised Age Profiles by Ethnicity 13

14. Ethnicity New Zealand 2014 The population has a relatively flat structure from childhood to age 55, with a steep decline in numbers thereafter. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health 14

15. 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 15

16. 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 16

17. 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 17

18. 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 18

19. Expected Deaths in New Zealand by DHB, financial year 2014 T Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health 19

20. Projected Ageing of Deaths by Ethnicity 20

21. Projected Deaths 2014 to 2026 All Deaths in New Zealand Over the period, the proportion of deaths over age 85 is expected to increase from 35.7% to 40.7%. Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health 21

22. Projected Deaths 2014 to 2026 Māori Deaths Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health Māori deaths tend to be at much younger ages. Deaths below age 65 are expected to decline with those at older ages increasing. 22

23. Projected Deaths 2014 to 2026 Pacific Deaths Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health Pacific deaths are also at younger ages. Like Māori deaths, deaths below age 65 are expected to decline with those at older ages increasing. 23

24. Projected Deaths 2014 to 2026 Asian Deaths Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health Asian deaths are expected to show the most rapid ageing over the period, with deaths over age 85 increasing from 18.5% to 36.5%. 24

25. Projected Deaths 2014 to 2026 Other Deaths Source: Analysis of projections produced by Statistics New Zealand according to assumptions specified by the Ministry of Health Deaths of the Other group, including NZ European, already occur at much older ages and there are very few deaths under age 65. Deaths over age 85 are expected to increase from 40.7% to 46.1%. 25

26. Deaths in New Zealand 2000-2010 30.1% of all deaths are over age 85. But 39.3% of female deaths are over age 85, while only 21.0% of male deaths are in that age band, Source: Analysis of Ministry of Health MORT data 2000 to 2010 26

27. Place of Death in New Zealand 2000 to 2010 April 2014 27

28. Place of Death 2000-2010 34.2% in hospital, 30.7% in residential care and 22.3% in private residence. Note that this seriously undercounts hospice involvement as only hospice inpatient unit available as a place of death. Source: Analysis of Ministry of Health MORT data 2000 to 2010 28

29. 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 29

30. Place of Death 2000-2010 Residential care accounts for 37.5% of female deaths but only 24.0 % of male deaths. Private residence accounts for only 18.4% of female deaths but 26.1% of male deaths. Source: Analysis of Ministry of Health MORT data 2000 to 2010 30

31. Place of Death 2000-2010 Note expanding funnel shape for residential care with age. Greater proportion of deaths of elderly women are in residential care, compared to elderly men. Source: Analysis of Ministry of Health MORT data 2000 to 2010 31

32. Place of Death 2000-2010 Age 85+ For deaths over age 85, 54.8% in residential care and only 9.9% in private residence. Some deaths in public hospital likely to be after transfer from residential care. Source: Analysis of Ministry of Health MORT data 2000 to 2010 32

33. Cause of Death and Place of Death Work-in-progress 33

34. Cause of Death 2000-2010 65% of deaths are from conditions other than neoplasms or external causes. Source: Analysis of Ministry of Health MORT data 2000 to 2010 34

35. Cause of Death 2000-2010 Females account for 49.9% of deaths from all causes. Source: Analysis of Ministry of Health MORT data 2000 to 2010 35

36. Place of Death 2000-2010 Neoplasms The largest proportion died in a private residence (28.2%), followed by hospital (26.5%), residential care (24.1%) and hospice inpatient unit (18.6%). Source: Analysis of Ministry of Health MORT data 2000 to 2010 36

37. Place of Death 2000-2010 Other Conditions The largest proportion died in hospital (38.5%), followed by residential care (35.9%) and a private residence (19.1%). Hospice inpatient unit was under 1% (0.9%) of deaths from other conditions. Source: Analysis of Ministry of Health MORT data 2000 to 2010 37

38. Place of Death 2000-2010 18.6% of deaths from Neoplasms in hospice inpatient unit. 68.4% of deaths from mental, behavioural and nervous system conditions are in residential care. Source: Analysis of Ministry of Health MORT data 2000 to 2010 38

39. Need for Palliative Care Work in progress … Need for palliative care by diagnosis Neoplasms Paediatric, adolescents and young adults Proportions needing palliative care in each setting Residential care 39

40. 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 Mobile: 0210 279 7425 40