TO THE EDITOR:
Where people die is an important determinant of patient and caregiver experience. To assess changes in place of death, we analyzed data from the Centers for Disease Control and Prevention and the National Center for Health Statistics database for natural deaths in the United States from 2003 through 2017. Cause of death was defined as the medical condition that had started the events that led directly to death, as recorded by the physician on the death certificate.1 Deaths from external causes were excluded. Between 2003 and 2017, there were nearly 35.2 million natural deaths (Figure 1). Most were attributed to cardiovascular disease (29.3%), followed by cancer (24.5%), respiratory disease (10.5%), dementia (7.9%), and stroke (5.9%).
In 2003, a total of 905,874 deaths occurred in hospitals (39.7%), which decreased to 764,424 (29.8%) in 2017, whereas the number of deaths at nursing facilities decreased from 538,817 (23.6%) to 534,714 (20.8%). The number of deaths at home increased from 543,874 (23.8%) in 2003 to 788,757 (30.7%) in 2017, whereas the number of deaths at hospice facilities increased from 5395 (0.2%) to 212,652 (8.3%). These trends were seen across all disease groups.
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. Patients with dementia had the greatest odds of death at a nursing facility, and patients with respiratory disease had the greatest odds of death at a hospital. Patients with stroke had the lowest odds of death at home, and patients with cardiovascular disease had the lowest odds of death at a hospice facility relative to other conditions.
Home has surpassed the hospital as the most common place of death in the United States for the first time since the early 20th century.2 Hospital deaths remained common in 2017, although the percentage in the United States was lower than in Canada (59.9%)3 and England (46.0%).4 Death at home is preferred by most people, but for many this might not be possible or preferable.5 Although we could not determine from the data whether hospice services were provided at home or at nursing facilities or whether some assisted-living facilities were categorized as home, data derived from death certificates provide the broadest assessment of place of death despite their limitations. 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. These findings should lead to prioritizing improvements in access to high-quality home care for older Americans with serious illnesses.
Sarah H. Cross, M.S.W., M.P.H.
Duke University Sanford School of Public Policy, Durham, NC
Duke University Sanford School of Public Policy, Durham, NC
Haider J. Warraich, M.D.
Veterans Affairs Boston Healthcare System, Boston, MA
hwarraich@partners.org
Veterans Affairs Boston Healthcare System, Boston, MA
hwarraich@partners.org
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
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