More Americans Dying at Home Than in Hospital

J.Adderton, BSN, MSN

This week, the New England Journal of Medicine reported that home is now the most common place Americans die of natural causes. For centuries, death was viewed as a natural process and those dying were cared for at home by family and community members. This changed in the early 1900s when the dying process became more medicalized and most people were in the hospital at the time of death. The current trend reflects the increasing rates of hospice enrollment for services that allow people to die where they want.

Study Method

The authors, Dr.Haider Warraich of the Veterans Affairs Boston Healthcare System and Duke University graduate student Sarah Cross, used government health statistics on natural deaths for the study. Data was analyzed from the Center for Disease Control and Prevent and the National Health Statistics database for deaths in the U.S. from 2003 to 2017, excluding deaths from external causes, such as accidents or homicides.

Study Findings

There were over 35.2 million deaths in the U.S. from 2003 to 2017, excluding deaths from external causes such as accidents. Cardiovascular disease was the leading cause (29.3%), followed by cancer (24.5%), respiratory disease (10.5%), dementia (7.9%) and stroke (5.9%).

Where Deaths Occur

The following table compares the findings for where people died in 2007 versus 2013:

Place of Death	2003	2017
Hospital	39.7%	29.8%
Nursing Facilities	23.6%	20.8%
Home	23.8%	30.7%
Hospice Facilities	0.2%	8.3%

Differences in Who You Are

The data analysis showed differences in place of death according to who you are, with nonwhites being less likely to die at home. According to the National Hospice & Palliative Care Organization (NHPCO), the demographics for Medicare hospice beneficiaries in 2017 are as follows:

83% White
8% African American
6.4% Hispanic
1.2% Asian
0.2% Native American

Several factors play a role in the low utilization of hospice among minorities. These may include:

Lack of awareness among patients, families and clinicians
Spiritual and religious beliefs that support preservation of life
Mistrust of the healthcare system
Organizational factors such as lack of interpreters and minority clinicians

Differences in Diagnosis

Data analysis also revealed patients with cancer were more likely to die at home or at a hospice facility. Patients with respiratory disease had the greatest odds of a hospital death and patients with a stroke had the lowest odds of dying at home.

The NHPCO published the following diagnosis statistics for Medicare hospice beneficiaries in 2017:

Cancer- 30%
Heart Disease- 17.6%
Dementia- 15.6%
Respiratory- 11%
Stroke- 9.4%
Chronic kidney disease- 2.3%

The Need for Conversations

As nurses, we can advocate for our patients by encouraging conversations with our patients, families and caregivers and the healthcare team about their wishes for end of life care. These conversations are important in helping patients, families and caregivers be on the same page when faced with making difficult decisions.

The Institute for Healthcare Improvement sponsors The Conversation Project to help us have conversations around end-of-life issues. A starter toolkit is available online for free download and print.

Moving Forward

The trends identified in the study show that progress is being made in end-of-life care. The authors identified a need for more information about the experience of patients dying at home. Understanding the patient's experience is critical to the development of policies and services that ensure quality end of life care.

Are you surprised by the study findings?

Additional information

Changes in the Place of Death in the United States

NHPCO Facts and Figures