Elsevier

Public Health

Volume 126, Issue 11, November 2012, Pages 937-946
Public Health

Original Research
Population, mortality and place of death in Germany (1950–2050) – Implications for end-of-life care in the future

https://doi.org/10.1016/j.puhe.2012.06.014Get rights and content

Summary

Objectives

European populations are ageing, but data on the associated end-of-life care needs are scarce. This study aimed to analyse population, mortality and place of death (PoD) trends in Germany since 1950, and to project mortality by PoD until 2050.

Study design and methods: Secondary analysis of national statistics on population, mortality and PoD by age and gender. Future numbers and proportions of deaths by PoD – hospital deaths (HDs) and non-hospital deaths (NHDs) – were based on recent trends (2005–2009). Linear models accounted for the effect of age and gender.

Results

The German population increased by 19.0% between 1950 and 2002, and has remained relatively stable ever since. However, it is expected that it will decrease (15.4%) from 2009 to 2050 (from 81.8 to 69.4 million). The annual number of deaths has shown an increasing trend, except for a decrease in 1975–2004. A 26.0% increase is expected from 2009 to 2050 (854,544 to 1,077,000 deaths). Older people (age ≥ 75 years) will account for 87.8% of all deaths in 2050 (64.4% in 2009). The proportion of HDs was stable, with an annual mean of 47.0% (range 44.9–47.8%). The models estimated that most people will continue to die outside of hospital in 2050 (48.6 or 54.1%), and absolute numbers of both HDs and NHDs will increase from 2009 to 2050 [HD: by 20.1 million (30.6%); NHD: by 35.5 million (17.0%)].

Conclusions

Unlike in other industrialized countries, most people in Germany die outside of hospital. The need to plan for growing end-of-life care needs and ageing is urgent in Germany but also applies to the rest of Europe. A joint European policy must inform national strategies.

Introduction

As in many parts of the world, populations in Europe are ageing and are expected to age further in the future.1 This is mainly due to longer life expectancy and low fertility.1 In 2009, 17.2% of the European population was aged ≥ 65 years; this age group is expected to account for 28.8% of all European citizens in 2050, with those aged ≥ 80 years projected to almost triple to 56.6 million.2 The rapid ageing in Europe poses an urgent public health problem of where and how best to care for increasing numbers of older people towards the end of life. Older people have special needs because they are more often affected by multiple medical problems, at greater risk of adverse drug reactions, and more often superimposed by mental impairment.3 In addition, the elderly are at high risk of poor symptom control (particularly for pain), and often experience a lack of information and involvement in decision-making (e.g. regarding end-of-life issues).4, 5

Germany is currently the third oldest country in the world, ageing ahead of all European countries apart from Italy.6, 7 There are ongoing debates about how this process has changed German society, and large investments are underway to develop ways to face the challenges of providing healthcare for older citizens.8, 9 Indeed, most of the healthcare provided to older people takes place during their last year of life.10 However, little is known about the extent to which future demographic changes will impact on end-of-life care needs. This is important to decide the capacity levels required and where to allocate resources with a view to best support people where they are and to enable them to die where they wish.

This study aimed to analyse population, mortality and place of death (PoD) trends in Germany since 1950, and to project future mortality by PoD until 2050.

Section snippets

Design, setting and timeframe

Secondary analysis of national data from the Federal Statistical Office (FSO) in Germany was undertaken. The unit of analysis was the whole of Germany, comprising the former Eastern part (German Democratic Republic) and the former Western part (Federal Republic of Germany). The analysis of past trends included years between 1950 and 2009 (before and after the reunification of the Eastern and Western parts in 1990).

Population and vital statistics

National data on the German resident population, births and deaths (1950–2009)

Population

From 1950 to 2002, the German resident population increased steadily by 19.0%, from 69.3 to 82.5 million. From 2002 onwards, the number of residents started to decrease (82.0 million in 2009). Several demographic changes contributed to this decrease, mainly the fall in the number of births and the rise in the number of deaths (Fig. 1).

Between 1950 and 1972, the annual number of births was always higher than the number of deaths, particularly during the ‘baby-boom’ in the 1960s. This changed in

Discussion

To the authors' knowledge, this is the first analysis of future mortality by PoD in Germany. The number of deaths is predicted to increase substantially until 2050. German citizens will die increasingly at advanced ages, and nearly half are expected to continue to die in hospitals. At the same time, the resident population is shrinking, with fewer young people to care for a greater number of older people. Ensuring that people live well towards the end of life is therefore increasingly important

Acknowledgements

The authors wish to thank the staff of the FSO in Germany for their help and advice to identify the appropriate data.

Ethical approval

Not required.

Funding

This work was supported by the Dr. Werner Jackstädt Foundation in Germany (Grant Number S 134–10.040) without involvement in study design, data collection, analysis, interpretation of the data, writing the report or submission of the study.

Competing interests

None declared.

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