More Deaths Now Occur in Homes than Hospitals, Nursing Facilities

For the first time since the early 20th Century more people are ending their lives in their homes rather than the hospital or a nursing facility, according to a new report that appeared in the New England Journal of Medicine.

The percentage of deaths that took place in a private residence rose to 30% in 2017, representing 788,757 decedents. This is up from 23.8% in 2003. Meanwhile, the number of deaths occurring in a hospital fell to 29.8% in 2017, compared to 39.7% in 2003. Similar reductions occurred in the number of decedents who expired in nursing facilities.

“Our findings have significant implications. They suggest that we are able to respect more Americans’ wishes to die at home than at any prior point in modern times, and this is largely due to the availability of hospice,” Haider J. Warraich, M.D., from the Veterans Affairs Boston Healthcare System told Hospice News. “This also reflects a cultural change in end-of-life care both among the public as well as physicians and nurses, a change brought about by years of tireless advocacy.”

Honoring patient wishes and goals at the end of their lives is an integral component of hospice and palliative care providers’ missions. About 80% of people in the United States say they would prefer to die in their homes, according to the U.S. Centers for Disease Control & Prevention. While more work is necessary to reach that 80%, the new data represents significant change.

The rise in deaths at home was not contingent on diagnosis. The trend occurred across all disease groups, according to the NEJM article, authored by Warraich and Sarah H. Cross of Duke University’s Sanford School of Public Policy.

The most frequently occurring causes of death among the decedents included in the study included cardiovascular disease, cancer, respiratory disease, dementia and stroke. The researchers defined “cause of death” as the medical condition that started the events that led directly to death as recorded by the physician on the death certificate, according to the NEJM paper.

The rise in deaths at home has gone hand in hand with a rise in hospice utilization. Record numbers of Medicare-insured patients elected hospice in 2018, rising above 50% for the first time since the formal inception of the Medicare Hospice Benefit in 1983.

The average length of stay also rose to 75 days in Q2 2018 from 74 in full-year 2017, according to Atlanta-based healthcare data analytics firm Trella Health.

“[The rise in home deaths] also sets the stage for increasing how much we support patients and caregivers at home,” Warraich said. “This involves not only supporting hospice better but also exploring other models of care that allow patients to be cared for at home.”

Disparities in how and where people die persist, however. Cross and Warraich reported that younger patients, female patients, and racial and ethnic minorities had lower odds of death at home than did older patients, male patients, and white patients. Patients with cancer had the greatest odds of death at home and death at a hospice facility and the lowest odds of death at a nursing facility relative to other conditions.

“The trends noted here represent progress; however, more information about the experience of patients dying at home is needed to develop policies and services that ensure high-quality end-of-life care,” the researchers wrote. “These findings should lead to prioritizing improvements in access to high-quality home care for older Americans with serious illnesses.”