Trends in place of death: The role of demographic and epidemiological shifts in end-of-life care policy

Background: Surveys suggest that most people prefer to die at home. Trends in causes of mortality and age composition could limit the feasibility of home deaths. Aim: To examine the effect of changes in decedents' age, gender and cause of death on the pattern of place of death using data on all deaths in Norway for the period 1987-2011. Design: Population-based observation study comparing raw, predicted, as well as standardised shares of place of death isolating the effect of demographic and epidemiological changes. The analysis was bolstered with joinpoint regression to detect shifts in trends in standardised shares. Setting/participants: All deaths (1,091,303) in Norway 1987-2011 by age, gender and cause of death. Place of death at home, hospital, nursing home and other. Results: Fewer people died in hospitals (34.1% vs 46.2%) or at home (14.2% vs 18.3%), and more in nursing homes (45.5% vs 29.5%) in 2011 than in 1987. Much of the trend can be explained by demographic and epidemiological changes. Ageing of the population and the epidemiological shift represented by the declining share of deaths from circulatory diseases (31.4% vs 48.4%) compared to the increase in deaths from neoplasms (26.9% vs 21.8%) and mental/behavioural diseases (4.4% vs 1.2%) are the strongest drivers in the shift in place of death. Joinpoint regression shows important differences between categories. Conclusion: Demographic and epidemiological changes go a long way in explaining shifts in place of death. The analyses reveal substantial differences in trends between different decedent groups.