More People Are Dying at Home Than in Hospitals, Report Says

More Americans are dying at home
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A new report published in the New England Journal of Medicine shows that more Americans are dying at home than in hospitals for the first time in nearly 50 years. The study looked at natural deaths that occurred in the United States between 2003 and 2017 and found about a 10 percent decrease in the number of people who died in a hospital during that time (39.7 percent and 29.8 percent respectively.) At the same time, the percentage of people who died at home increased from 23.8 percent in 2003 to 30.7 percent in 2017. Deaths at hospice facilities also increased over the time period, from 0.2 percent to 8.3 percent. 

The trend was seen across all diagnoses and demographic groups, although women, younger people and members of ethnic or racial minorities had a lesser chance of dying at home than older, white males. 

According to Dr. Haider J. Warraich, who co-authored the study, this is the first time since the mid-20th century that at-home deaths surpassed hospital deaths, reports the New York Times.  

Attitudes and Economics Fuel Change

A reflection of both shifting attitudes and the healthcare landscape, the increase in at-home deaths is, in some ways, predictable. Over the last few decades, Americans have begun to reject the medicalized, high-tech deaths that became the norm in the 1970s, choosing to shun the sterile atmosphere of the ICU and embrace a kinder, gentler death at home. Simultaneously, Medicare’s reimbursement structure has evolved in a way that incentivizes hospitals to discharge the terminally ill as quickly as they possibly can. 

The trend is viewed by many as a positive change. According to Carol Levine, an ethicist at New York’s United Hospital Fund, “There has been a kind of cultural shift that has romanticized dying at home and made it the only way to die.”

Many Americans are rejecting high-tech, medicalized death and choosing to die at home
Credit: statnews

But for too many patients, the reality of an at-home death falls far short of expectations, in large part because family caregivers are woefully unprepared to meet the dying person’s many needs.  

“We send very, very sick, complicated patients home under the care of family members who are not trained professionals,” said Dr. Diane Meier, a professor of geriatrics and palliative care physician at Mount Sinai Health System in New York. And while hospice is more readily available today than ever before, family caregivers are still expected to assume the lion’s share of the work of providing care. 

“We are, perhaps appropriately, shifting the site of care to where patients and families say they want to be,” said Dr. Sean Morrison, who chairs the department of geriatrics and palliative medicine at New York’s Mount Sinai Icahn School of Medicine. “But we have put a tremendous burden on families in the type of care they have to provide and the type they have to pay for” by doing so, he said. 

No Clear Cut Choice

Margaret Peterson, whose husband Dwight was a paraplegic who chose to die at home, tells a harrowing story of just how messy and unpredictable dying at home can be. Terrified of dying in a hospital, Dwight was enrolled in hospice in 2010, after his doctors agreed that he would likely succumb relatively quickly to his disease.But, like many hospice patients, Dwight defied the odds and lived another four, long years. 

Dr. Haider Warraich co-authored the study on American dying at home
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“It was absolutely exhausting,” Mrs. Peterson told the New York Times. And as her husband’s condition deteriorated, it became literally impossible for her to provide the care he required. After Dwight developed a deep bedsore on his foot, she was forced to enlist the help of a friend who was a vascular surgeon to help her care for the wound. 

“It was wonderful, but it’s like these GoFundMe things. We should not have to resort to a doctor to do us an enormous favor.” she said. 

In the end, Margaret says, her husband suffered horribly because she couldn’t control his pain at home and he refused to go to the hospital. 

“There is a kind of fantasy where if you make all the right choices, you get this beautiful and peaceful death,” she said. “But you can do everything right and still have an unpredictable and tragic experience,” she adds.