Location of death trends in the United States

1. Location of death trends in the United States Deepthi Mohankumar,PhD Postdoctoral Fellow Faculty of Nursing, University of Alberta

2. 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

3. 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

4. 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

5. 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.

6. 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)

7. 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

8. 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.

9. 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.

10. 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.