In America, the way we die is largely determined by where we live. Geography dictates what kind of care is provided to the dying and whether death following a long illness occurs at home, in a hospital or in a nursing home. But don't move just yet.
Patients can gain control over how they die by talking about end-of-life care with their families and physicians. If patients speak up, sheer numbers will force the health care system to take better care of the dying. Over the next 30 years, the number of people older than 85 will more than double to 9 million.
Our list of the Best Places To Die puts hard numbers on the quality of end-of-life health care and the ability of patients to make choices.
To create this state-by-state listing, we looked at the following criteria.
Health care quality
Rankings of health care quality come from a recent report from the Office of Clinical Standards and Quality at the Centers for Medicare & Medicaid Services.
Stephen F. Jencks and his colleagues looked at how health care had changed between 1998 and 2001 by examining, state by state, how well patients were treated for a variety of diseases, from heart disease to pneumonia. We used the latest available data, originally published in the Journal of the American Medical Association. These rankings comprised approximately 44 percent of our total ranking.
We looked at the legislative framework of each state in terms of the quality of their elder law.
In order to be able to rank the states, we used ratings based on an analysis by Charles Sabatino, JD, assistant director of the American Bar Association Commission on Law and Aging, that appeared in the 2002 report "Means to a Better End: A Report On Dying in America Today," published by Last Acts, a national coalition to improve care and caring at the end of life.
The report gave scores between 1 and 5 for all 50 states depending on how comprehensive and unified their legal framework was. To facilitate an immediate grasp of the data, we translated these scores into letter grades. These scores comprised about 9 percent of our final score.
Cancer deaths in hospital, in nursing homes or at home
Researchers at Brown University, led by Joan M. Teno, tracked exactly where cancer patients were likely to die. Most people want to die at home, and many complain about the care they received at nursing homes. We combined these two factors. States where people die at home will tend to do well here, and those where people die in nursing homes will do poorly. Together, these factors accounted for 22 percent of our ranking.
Percent Medicare patients using hospice in last year of life
When patients die at home, they still need health care. That's where hospice care comes in. These data come from the Dartmouth Atlas of Health and were contained in the "Means To A Better End" report. They are the percentage of patients, by state, who were cared for at home during their last year of life. Only Medicare patients over 65 who were not in health-maintenance organizations were included. This accounted for 22 percent of our total ranking.
Last, we looked at how estate tax laws vary from state to state. The results we have come up with are for an estate worth $10 million in 2004, legated by a widow or widower to their direct heirs. The computations were provided by BNA Software using their estate and gift tax CD-ROM planner. Because many states are in the process of changing the way they levy the estate tax, and because exemption levels will go up in future years, these results are only valid for 2004. They accounted for about 4 percent of our ranking.