Where do people want to die?

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.