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

Date Published: April 18, 2019

Publisher: Public Library of Science

Author(s): Woan Shin Tan, Ram Bajpai, Chan Kee Low, Andy Hau Yan Ho, Huei Yaw Wu, Josip Car, Janhavi Ajit Vaingankar.


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.

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.

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).

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.

Partial Text

Many middle- and high-income countries are currently facing the challenge of providing quality end-of-life care, and meeting patients’ preferences for dying at home. In a systematic review of 210 studies from 34 countries, 75% revealed that most people prefer to die at home. Home death preferences were found to be relatively stable, as only one in five studies reported changes as the patient’s disease progressed [1]. Despite a consistent preference for dying at home across these advanced societies, most decedents died in hospitals. Similarly, in Singapore, the rate of home death has been falling, despite a majority of Singaporeans (77%) indicating home death preferences [2]. In fact, 49% of Singaporean decedents died at home in 1965, as compared to 33% in 1990, and 25% in 2015 [3].

This is a retrospective cohort study, which included all adults (≥21 years old) who had died of malignant neoplasm, diabetes mellitus, heart and hypertensive disease, cerebrovascular disease, and lung and respiratory diseases between January 2012 and December 2015 in Singapore. We have excluded deaths due to infectious and parasitic diseases, accidents and violence, and other causes. This study was reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [26].

A total of 76,927 deaths occurred in Singapore between 2012 and 2015. For our analysis, we have excluded 1,209 as they were aged 21 years old or less at the point of death, 68 were excluded due to missing data. Of the 75,650 complete cases of adult deaths, 12,699 individuals were excluded from the analysis as they died from infectious and parasitic diseases, accidents and violence, and other causes. Nineteen percent of these excluded deaths occurred at home whereas the place of death due to chronic diseases are reflected in Table 2. The final analytical sample included 62,951 decedents. In this sample, 28% of these decedents died at home.

This study found that among adult decedents in Singapore, the likelihood of dying at home increased with certain individual and clinical factors, including age, being female, of Malay ethnicity, and lowered comorbid disease burden. Compared to individuals who died from malignant neoplasm, those who died from diabetes mellitus and cerebrovascular diseases were more likely to have died at home. Completion of advance statements and home palliative care, also contributed to a higher possibility of home death but admissions to acute hospitals near the end-of-life reduced this likelihood.

Our study illuminated the importance of home-based palliative care and ACP, as well as cultural and illness-specific factors in contributing to the eventual place of death. Our results imply that such policy initiatives could catalyse increases in the number of, and proportion of home deaths in the future. Scaling up these initiatives will help healthcare professionals better understand and support patients’ end-of-life preferences, if their wish was to spend their last days at home. Therefore, endeavoring to meet one’s preferences at the end-of-life cannot be constrained to just being the responsibility of the individual or family; it must encompass the resources and determined efforts of the community and society in creating a conducive, compassionate environment that supports people’s preferences of how and where they wish to die.




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