Individual, clinical and system factors associated with the place of death: A linked national database study

PLoS One. 2019 Apr 18;14(4):e0215566. doi: 10.1371/journal.pone.0215566. eCollection 2019.

Abstract

Background: Many middle- and high-income countries face the challenge of meeting preferences for home deaths. A better understanding of associated factors could support the design and implementation of policies and practices to enable dying at home. This study aims to identify factors associated with the place of death in Singapore, a country with a strong sense of filial piety.

Settings/participants: A retrospective cohort of 62,951 individuals (≥21 years old) who had died from chronic diseases in Singapore between 2012-2015 was obtained. Home death was defined as a death that occurred in a private residence whereas non-home deaths occurred in hospitals, nursing homes, hospices and other locations. Data were obtained by extracting and linking data from five different databases. Hierarchical multivariable logistic regression models were used to examine the effects of individual, clinical and system factors sequentially.

Results: Twenty-eight percent of deaths occurred at home. Factors associated with home death included being 85 years old or older (OR 4.45, 95% CI 3.55-5.59), being female (OR 1.21, 95% CI 1.16-1.25), and belonging to Malay ethnicity (OR 1.91, 95% CI 1.82-2.01). Compared to malignant neoplasm, deaths as a result of diabetes mellitus (OR 1.93, 95% CI 1.69-2.20), and cerebrovascular diseases (OR 1.28, 95% CI 1.19-1.36) were also associated with a higher likelihood of home death. Independently, receiving home palliative care (OR 3.45, 95% CI 3.26-3.66) and having a documented home death preference (OR 5.08, 95% CI 3.96-6.51) raised the odds of home deaths but being admitted to acute hospitals near the end-of-life was associated with lower odds (OR 0.92, 95% CI 0.90-0.94).

Conclusion: Aside from cultural and clinical factors, system-based factors including access to home palliative care and discussion and documentation of preferences were found to influence the likelihood of home deaths. Increasing home palliative care capacity and promoting advance care planning could facilitate home deaths if this is the desired option of patients.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Cause of Death
  • Chronic Disease
  • Databases, Factual*
  • Death
  • Female
  • Home Care Services
  • Hospices
  • Humans
  • Male
  • Middle Aged
  • Neoplasms / mortality*
  • Neoplasms / therapy
  • Palliative Care
  • Retrospective Studies
  • Singapore / epidemiology

Grants and funding

WST would like to acknowledge scholarship funding from the Singapore National Medical Research Council Research (NMRC) Training Fellowship; and the Singapore National Healthcare Group (NHG). This study was also funded by the Agency for Integrated Care Singapore to JC, which receives public funding from the Ministry of Health of the Singaporean Government. The funder has played no role in the study design, and the collection, analysis or interpretation of data presented in this manuscript.