chapter  7
14 Pages

Where the elderly die: the influence of socio-demographic factors and cause of death on people dying at home


The subject of place of death was brought to the forefront of the medical community in July 2004 when two important publications were released, one by the World Health Organization (Davies and Higginson, 2004) and another from the House of Commons Select Committee on Health (House of Commons Health Committee, 2004). Both reports highlighted that the proportion of deaths at home has been decreasing while that of hospital deaths has been increasing. The reports also pointed out a lack of congruence in that many patients died in hospitals, even though their expressed wishes were to spend their final days at home (Davies and Higginson, 2004; House of Commons Health Committee, 2004). The reports also discussed the wider implications on healthcare services, and the urgency to tackle the issues, as the place of death is where the patient will receive the care in his final illness. A study in the UK projected that deaths at home were likely to reduce by

24 per cent, with fewer than one in ten dying at home by 2030 (Higginson et al., 1998). In the USA, place of death was brought to public attention by the SUPPORT STUDY (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment), published in 1995 (Covinsky et al., 2000), and the Institute of Medicine report ‘Approaching death: improving care at the end of life’ in 1997 (Gomes and Higginson, 2004). Many studies have been done to understand the factors influencing where

people die and especially those factors affecting home deaths (Gomes and Higginson, 2004). Studies in the UK, Europe and the USA (Gomes and Higginson, 2004; McNamara and Rosenwax, 2007; Van Rensbergen et al., 2006; Weitzen et al., 2003) show that many factors influence the place of death: demographic factors (ethnicity, age, gender), social, cultural and religious factors, the disease and its therapy, having a caregiver, and the home environment or place of care (Covinsky et al., 2000). Van Rensbergen et al. (2006) refer to these collectively as the ‘social-contextual’ factors, with ‘contextual’ referring to the disease, the disease stage and the healthcare services available. Gruneir et al. (2007) showed the importance of both ‘social and structural characteristics’ in

influencing the end-of-life experience. ‘Structural’ is used to refer to the healthcare system, including the facilities and the payment system. Studies have also been done in Taiwan, a predominantly Chinese population, which showed that although ‘cultural concerns’ ranked high in influencing the patient’s decision, family caregivers give higher priority to quality of healthcare and the availability and ability of family caregivers when considering death at home (Tang et al., 2008). As the social contextual and social structural factors in Singapore may differ,

the purpose of this study is to identify the factors that are associated with the place of death, and especially deaths at home, in Singapore, a multiracial society.