Home is now the most common place of death in the U.S.

nL1N28L0DA - (Reuters Health) - For the first time in a least a half century, home has surpassed the hospital as the leading place to die in the United States.

A new analysis of death data, published in the New England Journal of Medicine, found that dying at home surpassed dying in the hospital beginning in 2017.

The last time more Americans died at home than at any other location “would have to be in the first half of the 20th century,” coauthor Dr. Haider Warraich told Reuters Health. “At least since the 1970s when we have reliable data, most people died in hospitals.”

Men, whites and older patients were more likely to die at home, as were people with cancer, the analysis found. People recovering from a stroke had the lowest odds of dying at home.

“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,” the researchers report.

The trends, seen in people with all types of disease, have been shifting for years.

From 2003 to 2017, the proportion of home deaths grew by 29% to the point where they accounted for 30.7% of deaths.

Meanwhile, hospital deaths during the same period declined by 25%, and hospitals were the place of death for 29.8% of Americans in 2017. Nursing facility deaths have also been on the decline, going from 23.6% to 20.8%.

Although still accounting for a small share in the place-of-death statistics, the biggest increase was in deaths in hospice facilities. They were the locale for 0.2% of deaths in 2003 and 8.3% in 2017, reflecting more than a 41-fold jump.

Hospice programs that let people die at home are a key reason home-based deaths have become so common, said Warraich, who is associate director of the Heart Failure Program in the Boston VA Healthcare System.

“More people dying at home is good news,” he told Reuters Health in a telephone interview. “It aligns with what people want. If you ask patients or loved ones where they would like to pass away, regardless of where you are or how sick you are, home is the number one choice. Being able to die at a familiar place becomes very important for many patients, even if it’s for a single day.”

The findings also suggest that the focus of the healthcare system needs to be shifted away from end-of-life hospital care. “As home becomes the place where most people die, this should catch the eye of policymakers who should ask how we should be providing more resources so people who want to die at home can do so,” Warraich said.

If hospice programs had better support and had the ability to offer more services, he speculated, even more people would choose to die at home.

The home death rate of 30.7% is still much lower than in Canada, which has a rate of 59.9%, and England, where the rate is 46.0%.

The results are complicated by the fact that some of the death certificates used in the study may have categorized assisted-living facilities as home. Also, it wasn’t always clear if hospice services were provided at home or in a nursing facility.

The analysis by Warraich and coauthor Sarah Cross of the Duke University Sanford School of Public Policy in Durham, North Carolina, did not look at what was motivating more people to die at home.

Financial issues, for example, “play a role in determining how people choose to experience the end of life, but it’s hard to know from these data what’s going on. We do know from other studies that people with a higher socioeconomic status are more likely to die at home in this country and other countries,” Warraich said.

“Dying at home may not be doable for many people who don’t have the resources needed to be comfortable at home,” he said.

For example, men - particularly married men - may be more likely to die at home because they have more support there.

SOURCE: The New England Journal of Medicine, online December 11, 2019.