Location of death trends in the United States Deepthi Mohankumar,PhD Postdoctoral Fellow Faculty of Nursing, University of Alberta
Determinants of location of death • Gender • Age • Socioeconomic status • Living arrangements • Feasibility of a good home death, functional status • Availability of nursing homes, hospice facilities • Preference for location of death
Changing location of death trends • Decrease in hospital deaths in the 1980s – 41% to 29% • Reverse trend in the 1990s – 30% to 60% • Family influences – fewer caregivers • State influences
Location of death trends -2 • Most frequent response to critical illness is to stave off death – the medical model • 25% of all hospitalized patients are treated in cardiac or intensive care units before death. • Influence of the Patient Self-Determination Act (PSDA) • Influence of the hospice movement
Relationship of place of death and access to home care services • Unequal distribution of ability to die at home. • Patients with informal caregiver support are more likely to die at home and access palliative home care. • Older individuals are less likely to die at home. • Women are less likely to die at home. • Individuals with cancer in higher socioeconomic groups are more likely to die at home.
Current trends in location of death • Living in a state with greater support for home and community based services is an indicator. • Effect of Medicaid (Muramatsu et al., 2008). • Higher prevalence of in-patient hospice deaths in terminally ill individuals, primarily cancer (Tang et al., 2004) • Distance from home (greater for individuals younger than 65)
Where do people die? • National Mortality Followback Survey- 60% of deaths occurred in hospitals, 20% in homes or nursing homes (Weitzen et al., 2003) • African-Americans, less educated, enrollment in an HMO- Predictors of hospital deaths. • Functional decline in the last 5 months of life associated with at home deaths. • PACE participants (45%) die at home (2002), 21% in hospitals vs. 53% Medicare beneficiaries
Death trends • Ethnic differences exist – Elderly minorities are more likely to die in inpatient settings. • Multilevel analysis with death certificates, county and state data (Gruneir et al.,2007): Disproportionate home deaths in Whites, higher education, greater access to community and social support, cancer deaths.
Implications • Research emphasis on demographic differences. • Overall hospital versus home versus nursing home changes are low over the last twenty years. • Preference versus actual location of death- characteristics of the local health care system has the most influence – availability of beds, closeness of hospice.
Health Care Reforms 2010 • Maintenance in funding for the Medicaid Follow the Money program through 2016 to transition individuals from nursing homes to communities. • Community First Choice Programs • Cash benefit to individuals using community based services for ADLs. • Independence at Home program for Medicare. • No end-of-life specifics.