Dying at home or in an institution: Using death certificates to explore the factors associated with place of death
Introduction
The place of death is presumed to be an important parameter of the quality of end-of-life care [1], [2], [3], [4], [5]. Interest in research about place of death often ensues from beliefs [3], [6], [7], [8] and proof [6], [9], [10], [11] of better overall end-of-life care for patients dying at home as well as better support for their next of kin. Some authors, however, dispute the a priori superiority of home death. Dying at home might not always be the best option and in some situations it might also be very stressful for others involved [12], [13]. Nevertheless, most authors agree that a “good death” may be one which is as much as possible in accordance with the patient's and family's wishes [3], [14], [15], [16]. Because, as is shown in research in other countries, there is an overall preference for dying at home [12], [17], [18], [19], [20], [21], it is striking that few deaths occur there [18], [22].
In this context it seems important for a public health policy that envisions the “good death” to study the place of death, but also to gain a better understanding of the reasons why people die where they do. Previous worldwide research highlighted a number of important determinants of place of death, but most of these studies focused on the death experience of cancer patients, were limited to specific settings of care or lacked robust statistical models [17]. In Belgium, very few and only rather limited studies of place of death have so far been conducted [23], [24].
In this study we include the whole population of deceased inhabitants in 2001 in Flanders, the northern Dutch-speaking region of Belgium where approximately 60% of the population lives. Due to the use of death certificates we can use large numbers (i.e. more statistical power) which gives good insight into the issue of place of death in relation to other factors and gives a good basis on which to interpret more qualitative studies. We investigate where deaths occurred, and investigate the associations with the place of death, to be expected from literature [7], [14], [16], [17], [25], [26], [27], [28], [29], [30], [31], [32], of clinical (e.g. cause of death), socio-demographic (e.g. age, presence of an informal caregiver, level of education), residential (e.g. degree of urbanization) and health care system factors (e.g. the number of available hospital beds in the region). Finally, we will formulate some research and policy implications of our findings.
Section snippets
Study design and data
In this study we performed analyses on data gathered within the context of cause of death statistics and health care statistics in Flanders (the largest region in Belgium, with six million inhabitants and approximately 55,000 deaths per year). The analyses presented here are based on all 55,772 deaths in 2001 of Flemish residents aged 1 year or older.
Place of death according to cause of death
Approximately half of all deaths occurred in hospital, one-fifth in a care home and a quarter at home. A small remaining group (2.2%) died elsewhere (e.g. public road, at work) (Table 1).
Deaths from natural causes occurred less often at home than deaths from external causes. The occurrence of home death was highest among patients with cardiovascular diseases (30.8%) or malignancies (29.1%). Ischemic heart disease patients had the highest home death rate (35.5%) compared to any other condition.
Discussion
Our results show that despite the fact that a large majority of dying people wish to die at home [8], [17], [18], [19], [20], [21], [22], [34], only a quarter of all deceased in our country actually did. We found that mainly disease related characteristics determine dying at home. Most cardiovascular patients, most cancer patients, but also patients suffering from lower respiratory diseases have a higher probability of dying at home than other patients. However, we also found important
Conclusions
Of all deaths in Flanders, more than half took place in a hospital, approximately a quarter at home and a fifth in a care home. The probability of home deaths varied by region, by rural or urban residence and by hospital bed availability in the region and was smaller among several non-malignant chronic diseases, lower educated people and people living alone. Although people often wish to die at home, most people in Flanders (Belgium) in 2001 did not die at home. The clinical, socio-demographic
Acknowledgements
The authors thank Koen Putman (researcher of the Department of Medical Sociology, Vrije Universiteit Brussel) and Lieve van den Block (researcher of the End-of-Life Care Research Group, Vrije Universiteit Brussel) for their assistance with this article.
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Deceased. Dr. Peter Hooft was a victim of the tsunami in Thailand on December 26, 2004. The final version of this article was completed after his disappearance, and he was thus not able to read or approve it.