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More Americans Dying at Home Than in Hospital

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J.Adderton has 27 years experience as a BSN, MSN .

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Are Americans Dying Where They Want?

Research has shown that 80% of Americans want to die at home. A new study found more people are experiencing end of life where they want but who you are and what you have makes a difference.

More Americans Dying at Home Than in Hospital

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

 

J. Adderton MSN has over 20 years experience in clinical leadership, staff development, project management and nursing education.

7 Followers; 117 Articles; 33,649 Profile Views; 380 Posts

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OUxPhys has 4 years experience as a BSN, RN and specializes in Cardiology.

823 Posts; 9,665 Profile Views

Heck yeah. After working in a hospital I dont want to die there. I want to die in my own bed, in my own home. Quick and painless. Hospice while being an inpatient in some facilities is a joke.

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HomeBound has 20 years experience and specializes in ED, ICU, Prehospital.

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No, I'm not surprised at all that the trend is towards being more humanistic and family oriented. Medicine as a global force scared the bejeezus out of pretty much everyone in the past 40 years--that you have to go to the hospital for everything so that you can get a pill for it or some type of "help".

We've been turned into a nation of helpless and fearful victims that can't seem to do anything for ourselves. Deliberately so. A helpless population is a weak population. Fear mongering is a great control mechanism for large populations. Fear of sickness. Fear of getting old. Fear of dying. You must be young and vibrant and beautiful, or else bad things happen.

I am happy to see the trend reversing.

"The wise man lives as long as he ought, not as long as he can." Marcus Aurelius (Meditations - Book II, 167 A.C.E.)

People may do well to begin practicing a little of the Stoicism that brought our ancestors through famine, disease and war.

You can't control anything but the way that you react to things.

Edited by HomeBound
additional thoughts

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ArmyRntoMD has 6 years experience as a BSN, RN and specializes in Critical Care.

314 Posts; 715 Profile Views

Why would anyone want to die in a hospital? 

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Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

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4 hours ago, ArmyRntoMD said:

Why would anyone want to die in a hospital? 

My brother in law wanted to die in hospice. He didnt want the family to have to permanently remember the house as where he took his last breath

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Swellz has 6 years experience and specializes in oncology, MS/tele/stepdown.

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On 12/28/2019 at 7:41 PM, Tenebrae said:

My brother in law wanted to die in hospice. He didnt want the family to have to permanently remember the house as where he took his last breath

Same with a long-term patient of mine. She didn't want her young children to associate their home with her death. She also wanted transfusions until very close to the end, so she stayed with us as opposed to going to hospice.

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babatee has 8 years experience as a MSN, RN and specializes in Geriatric, Acute, Rehab, Psychiatry.

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On 12/19/2019 at 7:40 PM, OUxPhys said:

Heck yeah. After working in a hospital I dont want to die there. I want to die in my own bed, in my own home. Quick and painless. Hospice while being an inpatient in some facilities is a joke.

well said

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16 Posts; 93 Profile Views

Both my grandparents passed away at home. I was able to be there for them in their final weeks.  It was peaceful and filled with love.  When my grandmother passed away 10 people were standing around her bed.  When my grandfather passed away about 15 people were sleeping in the house including 8 of his grandkids (I believe he waited until we were all asleep).  It was a graceful end to long-lived lives.

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