Place of death for patients with cancer in the United States, 1999 through 2015: Racial, age, and geographic disparities

Trends and Determinants of Location of Death Due to Colorectal Cancer in the United States : A Nationwide Study

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States (US); however, there are limited data on location of death in patients who die from CRC. We examined the trends in location of death and determinants in patients dying from CRC in the US.

METHODS

We utilized the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to extract nationwide data on underlying cause of death as CRC. A multinomial logistic regression was performed to assess associations between clinico-sociodemographic characteristics and location of death.

RESULTS

There were 850,750 deaths due to CRC from 2003 to 2019. There was a gradual decrease in deaths in hospital, nursing home, or outpatient facility/emergency department over time and an increase in deaths at home and in hospice. Relative to White decedents, Black, Asian, and American Indian/Alaska Native decedents were less likely to die at home and in hospice compared with hospitals. Individuals with lower educational status also had a lower risk of dying at home or in hospice compared with in hospitals.

CONCLUSIONS

The gradual shift in location of death of patients who die of CRC from institutionalized settings to home and hospice is a promising trend and reflects the prioritization of patient goals for end-of-life care by healthcare providers. However, there are existing sociodemographic disparities in access to deaths at home and in hospice, which emphasizes the need for policy interventions to reduce health inequity in end-of-life care for CRC.

Geographic Information Systems Utilization in Pediatric End-of-Life Research: A Scoping Review

Currently, little is known about how geographic information systems (GIS) has been utilized to study end-of-life care in pediatric populations. The purpose of this review was to collect and examine the existing evidence on how GIS methods have been used in pediatric end-of-life research over the last 20 years. Scoping review method was used to summarize existing evidence and inform research methods and clinical practice was used. The Preferred Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA) was utilized. The search resulted in a final set of 17 articles. Most studies created maps for data visualization and used ArcGIS as the primary software for analysis. The scoping review revealed that GIS methodology has been limited to mapping, but that there is a significant opportunity to expand the use of this methodology for pediatric end-of-life care research.

Trends in Location of Death for Individuals With Ovarian Cancer in the United States

Using the publicly available Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database from 2003 to 2019, we evaluated associations between decedent characteristics and location of death for patients with ovarian malignancy. We found that Black, Native American, Asian American, and Hispanic patients were more likely to die in hospitals than White patients, despite an overall reduction in hospital deaths and an overall increase in hospice facility deaths. Additionally, patients with lesser educational attainment were more likely to die in nursing facilities and less likely to die in hospice facilities. Although there may be some contribution from cultural preferences, these findings may represent disparities in access to palliative care affecting people with cancer from racial and ethnic minoritized groups.

Social Deprivation and End-of-Life Care Use Among Adults With Cancer

PURPOSE

Socioeconomic differences are partially responsible for racial inequities in cancer outcomes, yet the association of area-level socioeconomic disadvantage and race with end-of-life (EOL) cancer care quality is poorly understood.

METHODS

This retrospective study used electronic medical records from an academic health system to identify 33,635 adults with cancer who died between 2013 and 2019. Using multivariable logistic regression, we examined associations between decedent characteristics and EOL care, including emergency department (ED) visits, intensive care unit (ICU) stays, palliative care consultation (PCC), hospice order, and in-hospital deaths. Social deprivation index was used to measure socioeconomic disadvantages.

RESULTS

Racially minoritized decedents had higher odds of ICU stay than the least deprived White decedents (eg, other race Q3: aOR, 2.06 [99% CI, 1.26 to 0.3.39]). White and Black decedents from more deprived areas had lower odds of ED visit (White Q3: aOR, 0.382 [99% CI, 0.263 to 0.556]; Black Q3: aOR, 0.566 [99% CI, 0.373 to 0.858]) than least deprived White decedents. Compared with White decedents living in least deprived areas, racially minoritized decedents had higher odds of receiving PCC and hospice order, whereas White decedents in most deprived areas had lower odds of PCC (aOR, 0.727 [99% CI, 0.592 to 0.893]) and hospice order (aOR, 0.845 [99% CI, 0.724 to 0.986]). Greater deprivation was associated with greater odds of hospital death relative to least deprived White decedents, but only among minoritized decedents (eg, Black Q4: aOR, 2.16 [99% CI, 1.82 to 2.56]).

CONCLUSION

Area-level socioeconomic disadvantage is not uniformly associated with poorer EOL cancer care, with differences among decedents of different racial groups.

Place of Death for Israeli Cancer Patients Over a 20-Year Period: Reducing Hospital Deaths, but Barriers Remain

BACKGROUND

Cancer remains a leading cause of mortality worldwide. While the main focus of palliative care (PC) is quality of life, the elements that comprise the quality of death are often overlooked. Dying at home, with home-hospice-care (HHC) support, rather than in-hospital, may increase patient satisfaction and decrease the use of invasive measures. We examined clinical and demographic characteristics associated with out-of-hospital death among patients with cancer, which serves as a proxy measure for HHC deaths.

METHODS

Using death certification data from the Israel Central Bureau of Statistics, we analyzed 209,158 cancer deaths between 1998 and 2018 in Israel including demographic information, cause of death, and place of death (POD). A multiple logistic regression model was constructed to identify factors associated with out-of-hospital cancer deaths.

RESULTS

Between 1998 and 2018, 69.1% of cancer deaths occurred in-hospital, and 30.8% out-of-hospital. Out-of-hospital deaths increased by 1% annually during the study period. Older patients and those dying of solid malignancies were more likely to die out-of-hospital (OR = 2.65, OR = 1.93, respectively). Likelihood of dying out-of-hospital varied with area of residency; patients living in the Southern district were more likely than those in the Jerusalem district to die out-of-hospital (OR = 2.37).

CONCLUSION

The proportion of cancer deaths occurring out-of-hospital increased during the study period. We identified clinical and demographic factors associated with POD. Differences between geographical areas probably stem from disparity in the distribution of PC services and highlight the need for increasing access to primary EOL care. However, differences in age and tumor type probably reflect cultural changes and suggest focusing on educating patients, families, and physicians on the benefits of PC.

Disparities in testicular cancer incidence, mortality, and place of death trends from 1999 to 2020: A comprehensive cohort study

BACKGROUND

Testicular cancer (TC) mortality rates have decreased over time, however it is unclear whether these improvements are consistent across all communities.

AIMS

The aim of this study was to analyze trends in TC incidence, mortality, and place of death (PoD) in the United States between 1999-2020 and identify disparities across race, ethnicity, and geographic location.

METHODS AND RESULTS

This cross-sectional study used CDC WONDER and NAACCR, to calculate age-adjusted rates of TC incidence and mortality, respectively. PoD data for individuals who died of TC were collected from CDC WONDER. Using Joinpoint analysis, longitudinal mortality trends were evaluated by age, race, ethnicity, US census region, and urbanization category. TC stage (localized vs metastatic) trends were also evaluated. Univariate and multivariate regression analysis identified demographic disparities for PoD. A total of 8,456 patients died of TC from 1999-2020. Average annual percent change (AAPC) of testicular cancer-specific mortality (TCSM) remained largely stable (AAPC, 0.4; 95% CI -0.2 to 0.9; p = 0.215). Men ages 25-29 experienced a significant increase in TCSM (AAPC, 1.3, p = 0.003), consistent with increased metastatic testicular cancer-specific incidence (TCSI) trend for this age group (AAPC, 1.6; p < 0.01). Mortality increased for Hispanic men (AAPC, 1.7, p < 0.001), with increased metastatic TCSI (AAPC, 2.5; p < 0.001). Finally, younger (<45), single, and Hispanic or Black men were more likely to die in medical facilities (all p < 0.001). The retrospective study design is a limitation.

CONCLUSION

Significant increases in metastatic TC were found for Hispanic men and men aged 25-29 potentially driving increasing testicular cancer specific mortality in these groups. Evidence of racial and ethnic differences in place of death may also highlight treatment disparities.

End-of-life interventions in patients with cancer

OBJECTIVES

To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site.

METHODS

We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site.

RESULTS

Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates.

CONCLUSIONS

Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.

Factors associated with home death in South Korea: Using the exit data from the Korean Longitudinal Study of Aging, 2008-2018

BACKGROUND

Even though home deaths have been reported to improve quality of life, satisfy patients and families, and reduce healthcare expenditures, not enough is known about the factors that influence home deaths in Korea.

OBJECTIVES

This study aimed to examine the factors associated with home deaths among middle-aged and older adults in South Korea.

METHODS

This secondary data analysis used core interview and exit interview data of the Korean Longitudinal Study of Aging conducted between 2008 and 2018. The deceased included adults over the age of 45 years. The exit data were obtained from interviews with family members or other acquaintances known to the deceased every two years since 2008. Complex-sample logistic regression was conducted using 1,565 middle-aged and older deceased adults.

RESULTS

Among 1,565 decedents, the average age at the time of death was 80.67±10.69 in the home death group, and 78.72±9.83 in the non-home death group. The proportion of home-related deaths was 26.4%. Age over 81 years was associated with increased odds of home death, whereas having two or more living children, living in town/small city, paid medical expenses by children/grandchildren and their spouses, expected death, death from disease, and having three or more chronic diseases were associated with decreased odds of home death. An increase in activities of daily living during three months before death was associated with a decrease in home death.

CONCLUSION

The findings could help healthcare professionals develop tailored interventions to help people die at their preferred place of death based on family characteristics and healthcare accessibility. Age, residential area, number of children and children's financial support, and illness-related factors influenced home death by creating differences in access to healthcare resources and support. Policymakers should decrease healthcare disparities and improve health resource allocation and home-based care.

Effect of the COVID-19 Pandemic on Place of Death Among Medicaid and Commercially Insured Patients With Cancer in Washington State

PURPOSE

The COVID-19 pandemic-related disruptions in health care delivery might have affected end-of-life care in patients with cancer. We examined changes in place of death and hospice support for Medicaid and commercially insured patients during the pandemic.

PATIENTS AND METHODS

We linked Washington State cancer registry records with claims from Medicaid and two commercial insurers for patients with solid tumor age 18-64 years. The study included 322 Medicaid and 162 commercial patients who died between March 2017 and June 2019 (pre-COVID-19), along with 90 Medicaid and 47 commercial patients who died between March and June 2020 (COVID-19). Place of death was categorized as hospital, hospice (home or nonhospital facility), and home without hospice. Place of death was compared using adjusted multinomial logistic regressions stratified by payer and time period (pre-COVID-19 v COVID-19). The clinical and sociodemographic factors associated with dying at home without hospice were examined, and adjusted marginal effects (ME) are reported.

RESULTS

In the adjusted pre-COVID-19 analysis, Medicaid patients were more likely than commercially insured patients to die in hospital (48% v 36%; adjusted ME, 11%; P = .02). In the pre-COVID-19/COVID-19 analysis, Medicaid patients' place of death shifted from hospital (48% v 32%; ME, -16%; P < .01) to home without hospice (19.9% v 38.0%; ME, 16.5%; P < .01). However, there were no statistically significant changes pre-COVID-19/COVID-19 for commercial patients. As a result, during COVID-19, Medicaid patients were more likely than commercial patients to die at home without hospice (38% v 22%; ME, 16%; P = .04) as were male versus female patients (ME, 16%; P < .01).

CONCLUSION

The pandemic might have disproportionately worsened the end-of-life experience for Medicaid enrollees with cancer. Attention should be paid to societal and health system factors that decrease access to care for Medicaid patients.

Racial and ethnic disparities in end-of-life care for patients with oesophageal cancer: death trends over time

Background

Given significant morbidity and mortality associated with oesophageal cancer, supportive, high-quality end-of-life care is critical. Most patients with advanced cancer prefer to die at home, but incongruence between preferred and actual place of death is common. Here, we examined trends and disparities in location of death among patients with oesophageal cancer.

Methods

Using the Centers for Disease Control and Prevention Wide-Range Online Data for Epidemiologic Research database, we utilized multinomial logistic regression to assess associations between sociodemographic characteristics and location of death for patients with oesophageal cancer (n = 237,063). Additionally, we utilized linear regression models to evaluate the significance of changes in location of death trends over time and disparities in the relative change in location of death trends across sociodemographic groups.

Findings

From 2003 to 2019, there was a decrease of deaths in hospitals, nursing homes, and outpatient medical facilities/emergency departments and an increase of deaths at home and in hospice. Relative to White decedents, Black and Asian decedents were less likely to die at home (relative risk ratio (RRR): 0.58 [95% confidence interval (CI): 0.56-0.60], RRR: 0.57 [95% CI: 0.53-0.61]) and in hospice (RRR: 0.67 [95% CI: 0.64-0.71], RRR: 0.49 [95% CI: 0.43-0.55]) when compared to the hospital. Similar disparities were noted for American Indian and Alaska Native (AIAN) decedents. These disparities persisted even upon stratifying by the number of listed causes of death, a proxy for severity of illness. Time trend analysis indicated that increases in deaths in hospice over time occurred at a slower rate for AIAN and Asian decedents relative to White decedents.

Interpretation

2 in 5 patients with oesophageal cancer die at home, with an increasing proportion dying at home and in hospice-in line with general patient preferences. However, location of death disparities have largely persisted over time among racial and ethnic minority groups. Our findings suggest the importance of improving access to advance care planning and delivering tailored, person-centred interventions.

Funding

None.

A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness

Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.

Place of death among individuals with chronic respiratory diseases in China: Trends and associated factors between 2014 and 2020

Background

Chronic respiratory disease (CRD) is a common cause of mortality in China, but little is known about the place of death (POD) among individuals with CRD.

Methods

Information about CRD-caused deaths was obtained from the National Mortality Surveillance System (NMSS) in China, covering 605 surveillance points in 31 provinces, autonomous regions, and municipalities. Both individual- and provincial-level characteristics were measured. Multilevel logistic regression models were built to evaluate correlates of hospital CRD deaths.

Results

From 2014 to 2020, a total of 1,109,895 individuals who died of CRD were collected by the NMSS in China, among which home was the most common POD (82.84%), followed by medical and healthcare institutions (14.94%), nursing homes (0.72%), the way to hospitals (0.90%), and unknown places (0.59%). Being male, unmarried, having a higher level of educational attainment, and being retired personnel were associated with increased odds of hospital death. Distribution of POD differed across the provinces and municipalities with different development levels, also presenting differences between urban and rural. Demographics and individual socioeconomic status (SES) explained a proportion of 23.94% of spatial variations at the provincial level. Home deaths are the most common POD (>80%) among patients with COPD and asthma, which are the two major contributors to CRD deaths.

Conclusion

Home was the leading POD among patients with CRD in China in the study period; therefore, more attention should be emphasized to the allocation of health resources and end-of-life care in the home setting to meet the increasing needs among people with CRD.

Racial and ethnic differences in retrospective end-of-Life outcomes: A systematic review

The purpose of this systematic review was to provide a comprehensive account of racial and ethnic differences in retrospective end-of-life outcomes. Studies were searched from the following databases: Abstracts in Social Gerontology, Academic Search Premier, CINAHL Plus with Full Text, ERIC, MEDLINE, PsycINFO, PubMED, and SocIndex. Studies were included if they were published in English, included people from groups who have been minoritized, included adults aged 18 and older, used retrospective data, and examined end-of-life outcomes. Results from most of the 29 included studies showed that people from groups who have been minoritized had more aggressive/intensive care, had less hospice care, were more likely to die in a hospital, less likely to engage in advance care planning, less likely to have good quality of care, and experienced more financial burden at the end of life. Implications for practice (timely referrals), policy (health insurance access), and research (intervention studies) are provided.

Equal receipt of specialized palliative care in breast and prostate cancer: a register study

PURPOSE

There are inequalities in cancer treatment. This study aimed to investigate whether receipt of specialized palliative care (SPC) is affected by typical female and male diagnoses (breast and prostate cancer), age, socioeconomic status (SES), comorbidities as measured by the Charlson Comorbidity Index (CCI), or living arrangements (home vs nursing home residence). Furthermore, we wanted to investigate if receipt of SPC affects the place of death, or correlated with emergency department visits, or hospital admissions.

METHODS

All breast and prostate cancer patients who died with verified distant metastases during 2015-2019 in the Stockholm Region were included (n = 2516). We used univariable and stepwise (forward) logistic multiple regression models.

RESULTS

Lower age, lower CCI score, and higher SES significantly predicted receipt of palliative care 3 months before death (p = .007-p < .0001). Patients with prostate cancer, a lower CCI score, receiving palliative care services, or living in a nursing home were admitted to a hospital or visited an emergency room less often during their last month of life (p = .01 to < .0001). Patients receiving palliative care services had a low likelihood of dying in an acute care hospital (p < .001). Those who died in a hospital were younger, had a lower CCI score, and had received less palliative care or nursing home services (p = .02- < .0001).

CONCLUSION

Age, comorbidities, and nursing home residence affected the likelihood of receiving SPC. However, the diagnosis of breast versus prostate cancer did not. Emergency room visits, hospital admissions, and hospital deaths are registered less often for patients with SPC.

Patient-Centered and Family-Centered Care in the Intensive Care Unit

Patient-centered and family-centered care (PFCC) is widely recognized as integral to high-quality health-care delivery. The highly technical nature of critical care puts patients and families at risk of dehumanization and renders the delivery of PFCC in the intensive care unit (ICU) challenging. In this article, we discuss the history and terminology of PFCC, describe interventions to promote PFCC, highlight limitations to the current model, and offer future directions to optimize PFCC in the ICU.

Where Are We Dying? Ethnic Differences in Place of Death Among New Zealanders Dying of Cancer

Around a third of people with cancer will die outside of their preferred place of death, with substantial variation occurring between and within countries in terms of place of death. Here, we examine place of death within the New Zealand cancer context, with specific focus on differences between Indigenous Māori and other ethnic groups.

National study reveals substantial differences in place of cancer death between ethnic groups in NZ.

Racial Disparities in the Provision of Pediatric Psychosocial End-of-Life Services: A Systematic Review

Background: When compared with White patients, racial and ethnic minorities experience greater barriers to quality end-of-life care. Each year, approximately 52,000 children die in the United States, yet little is known about the disparities in pediatric palliative care, especially when looking at psychosocial palliative care services such as those provided by child life specialists, social workers, and pediatric psychologists. Objectives: In an effort to consolidate and synthesize the literature on this topic for psychosocial professionals working with children and families confronting a life-threatening diagnosis, a review was conducted. Design: This work was a systematic review of several academic databases that were searched from January 2000 to December 2020 for studies exploring disparities in pediatric end-of-life services and written in English. Setting/Subjects: This review was conducted in the United States. The search yielded 109 articles, of which 16 were included for review. Measurements: Three psychosocial researchers independently reviewed, critically appraised, and synthesized the results. Results: Emerging themes from the literature (n = 16) include service enrollment, decision making, and communication. Results highlight a lack of research discussing psychosocial variables and the provision of psychosocial services. Despite this gap, authors were able to extract recommendations relevant to psychosocial providers from the medical-heavy literature. Conclusions: Recommendations call for more research specific to possible disparities in psychosocial care as this is vital to support families of all backgrounds who are confronting the difficulties of pediatric loss.

Trends in Location of Death Among Older Adult Americans After Falls

Introduction: Fall-related mortality is increasing among older adults, yet trends and changes in the location of fall-attributed deaths are unknown; additionally, potential disparities are understudied. Methods: To assess trends/factors associated with place of death among older adult fall deaths in the US, a cross-sectional analysis of deaths using mortality data from 2003–2017 was performed. Results: Most deaths occurred in hospitals, however, the proportion decreased from 66.4% (n = 9,095) to 50.7% (n = 15,817). The proportion occurring in nursing facilities decreased from 15.9% (n = 2175) to 15.3% (n = 4,778), while deaths at home and in hospice facilities increased. Male, Black, Native American, and married decedents had increased odds of hospital death. Conclusion: As fall deaths increase among older adults, end-of-life needs of this population deserve increased attention. Research should explore needs and preferences of older adults who experience falls and their caregivers to reduce disparities in place of death and to ensure high quality of care is received.

Impact of Augmented Intelligence on Utilization of Palliative Care Services in a Real-World Oncology Setting

PURPOSE

For patients with advanced cancer, timely referral to palliative care (PC) services can ensure that end-of-life care aligns with their preferences and goals. Overestimation of life expectancy may result in underutilization of PC services, counterproductive treatment measures, and reduced quality of life for patients. We assessed the impact of a commercially available augmented intelligence (AI) tool to predict 30-day mortality risk on PC service utilization in a real-world setting.

METHODS

Patients within a large hematology-oncology practice were scored weekly between June 2018 and October 2019 with an AI tool to generate insights into short-term mortality risk. Patients identified by the tool as being at high or medium risk were assessed for a supportive care visit and further referred as appropriate. Average monthly rates of PC and hospice referrals were calculated 5 months predeployment and 17 months postdeployment of the tool in the practice.

RESULTS

The mean rate of PC consults increased from 17.3 to 29.1 per 1,000 patients per month (PPM) pre- and postdeployment, whereas the mean rate of hospice referrals increased from 0.2 to 1.6 per 1,000 PPM. Eliminating the first 6 months following deployment to account for user learning curve, the mean rate of PC consults nearly doubled over baseline to 33.0 and hospice referrals increased 12-fold to 2.4 PPM.

CONCLUSION

Deployment of an AI tool at a hematology-oncology practice was found to be feasible for identifying patients at high or medium risk for short-term mortality. Insights generated by the tool drove clinical practice changes, resulting in significant increases in PC and hospice referrals.

Place of Death of Geriatric Population in Turkey: A 7-Year Observational Study

BACKGROUND

End-of-life care has become an important public health issue in recent years. Place of death is a major component of end-of-life care. Despite attempts to improve end-of-life care, there has not been published any data about place of deaths in Turkey. Aim: This retrospective, cross-sectional study investigates the place of death and trends over the years in geriatric age groups in Turkey. Methods: Patients who were admitted to geriatric outpatient clinic of a university hospital during a 7-year period were included. Place and date of death information were received from the death notification system and recorded as hospital or out-of-hospital death. Demographic and clinical data were collected from the hospital information system. Deaths occurring after March 1, 2020 were not included to eliminate the effect of coronavirus disease-2019 pandemic. Results: A total of 4025 (20.7%) patients were determined to be dead. Approximately three-quarters of deaths (73.0%) occurred in hospital. The number of deaths reported from nursing homes was only 13 (3.0%). Patients with dementia less frequently died in hospital, however, it was not statistically significant (12.4% vs 14.7%, P = .05). The prevalence of death in hospital was significantly higher in patients with chronic renal failure (3.1% vs 1.7%, P = .02). The presence of comorbid conditions such as heart failure, cerebrovascular disease, Parkinson's disease, chronic obstructive pulmonary disease/asthma, and cancer did not affect the place of death (P = .24, .21, .24, .51, and .18). Out-of-hospital mortality increased with advanced age (P < .001). No significant difference was found in the place of death over the years (P = .41). Conclusion: To the best of our knowledge, this is the first study examining the place of death in Turkey, an aging country. Our results may help to establish policies about end-of-life care in elderly people to improve quality of life by using resources effectively.

Deaths from hepatocellular carcinoma are more likely to occur in medical facilities than deaths from other cancers: 2003-2018

Place of death is a key indicator of quality of end-of-life care, and most people with a terminal diagnosis prefer to die at home. Home has surpassed the hospital as the most common location of all-cause and total cancer-related deaths in the United States. However, trends in place of death due to hepatocellular carcinoma (HCC), which is uniquely comanaged by hepatologists and oncologists, have not been described. We analysed US death certificate data from 2003 to 2018 for the proportion of deaths over time at medical facilities, nursing facilities, hospice facilities and home, for HCC and non-HCC cancer. The proportion of deaths increased from 0.6% to 15.2% in hospice facilities (P trend < 0.0001) but did not change at home. In multivariable analysis, persons with HCC were more likely than persons with non-HCC cancer to die in medical facilities, while persons with HCC were less likely to die at home.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

OBJECTIVES

Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.

METHODS

The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.

DISCUSSION

Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

Hospitalization at the end of life in patients with multiple myeloma

BACKGROUND

Despite advances in treatment, multiple myeloma (MM) remains incurable and results in significant morbidity and mortality. Further research investigating where MM patients die and characterization of end-of-life hospitalizations is needed.

METHODS

We utilized the National Inpatient Sample (NIS) to explore the hospitalization burden of MM patients at the end of their lives.

RESULTS

The percent of patients dying in the hospital as a percent of overall MM deaths ranged from 54% in 2002 to 41.4% in 2017 (p < 0.01). Blood transfusions were received in 32.7% of these hospitalizations and infections were present in 47.8% of patients. Palliative care and/or hospice consultations ranged from 5.3% in 2002 to 31.4% in 2017 (p < 0.01).

CONCLUSION

Our study demonstrates that patients with MM dying in the hospital have a significant requirement for blood transfusions and have a high infection burden. We also show that palliative care and hospice involvement at the end of life has increased over time but remains low, and that ultimately, inpatient mortality has decreased over time, but MM patients die in the hospital at a higher rate than the general population.

National Trends in Location of Death in Patients With End-Stage Liver Disease

Despite improvement in the care of patients with end-stage liver disease (ESLD), mortality is rising. In the United States, patients are increasingly choosing to die at hospice and home, but data in patients with ESLD are lacking. Therefore, this study aimed to describe the trends in location of death in patients with ESLD. We conducted a retrospective cross-sectional analysis using the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research from 2003 to 2018. Death location was categorized as hospice, home, inpatient facility, nursing home, or other. Comparisons were made between sex, age, ethnicity, race, region, and other causes of death. Comparisons were also made between rates of change (calculated as annual percent change), proportion of deaths in 2018, and multivariable logistic regression. A total of 535,261 deaths were attributed to ESLD-most were male, non-Hispanic, and White. The proportion of deaths at hospice and home increased during the study period from 0.2% to 10.6% and 20.3% to 25.7%, respectively. Whites had the highest proportion of deaths in hospice and home. In multivariable analysis, elderly patients were more likely to die in hospice or home (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.07-1.35), whereas Black patients were less likely (OR, 0.58; 95% CI, 0.46-0.73). Compared with other causes of death, ESLD had the second highest proportion of deaths in hospice but lagged behind non-hepatocellular carcinoma malignancy. Deaths in patients with ESLD are increasingly common at hospice and home overall, and although the rates have been increasing among Black patients, they are still less likely to die at hospice or home. Efforts to improve this disparity, promote end-of-life care planning, and enhance access to death at hospice and home are needed.

Trends in Place of Death for Individuals With Deaths Attributed to Advanced Chronic or End-Stage Kidney Disease in the United States

CONTEXT

An important aspect of end-of-life care, place of death is understudied in advanced chronic (CKD) and end-stage kidney disease (ESKD).

OBJECTIVE

We sought to examine trends and factors associated with where advanced CKD/ESKD patients die.

METHODS

We conducted a retrospective cross-sectional study using mortality data from 2003 to 2017 for deaths attributed primarily to advanced CKD/ESKD in the United States.

RESULTS

Between 2003 and 2017, 222,247 deaths were attributed to advanced CKD/ESKD. From 2003 to 2017, deaths occurring in hospitals declined from 56.0% (n = 5356) to 35.6% (n = 7764), whereas increases occurred in deaths at home (13.5% [n = 1292] to 24.3% [n = 5306]), nursing facilities (18.6% [n = 1776] to 19.3% [n = 4221]), and hospice facilities (0.3% [n = 29] to 13.4% [n = 2917]). Nonwhite race was associated with increased odds of hospital death (Black [OR = 1.59; 95% CI = 1.55, 1.62]; Native American [OR = 1.47; 95% CI = 1.32, 1.63]; Asian [OR = 1.43; 95% CI = 1.32, 1.55] and reduced odds of nursing facility (Black [OR = 0.622; 95% CI = 0.600, 0.645]; Native American [OR = 0.638; 95% CI = 0.572, 0.712]; Asian [OR = 0.574; 95% CI = 0.533, 0.619], or hospice facility death (Black [OR = 0.843; 95% CI = 0.773, 0.918]; Native American [OR = 0.380; 95% CI = 0.289, 0.500]; Asian [OR = 0.609; 95% CI = 0.502, 0.739]). Older age was associated with reduced odds of hospital death (≥85 [OR = 0.334; 95% CI = 0.312, 0.358]) and increased odds of home (≥85 [OR = 1.55; 95% CI = 1.43, 1.68]), nursing facility (≥85 [OR = 3.09; 95% CI = 2.76, 3.45]) or hospice facility death (≥85 [OR = 1.60; 95% CI = 1.49, 1.72]).

CONCLUSIONS

Hospitals remain the most common place of death from advanced CKD/ESKD; however, the proportion of home, nursing facility, and hospice facility deaths have increased.

Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities?

BACKGROUND

Place of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer.

METHODS

Deidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables.

RESULTS

From 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%.

CONCLUSION

Hospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.

The Black and White of Invasive Mechanical Ventilation in Advanced Dementia

BACKGROUND/OBJECTIVES

Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation.

DESIGN

Retrospective cohort study.

SETTING

Acute-care hospitals in the United States.

PARTICIPANTS

Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race.

MEASUREMENT

Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV.

RESULTS

Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51).

CONCLUSION

IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

Deaths from heart failure and cancer: location trends

BACKGROUND

Increasing utilisation of hospice services has been a major focus in oncology, while only recently have cardiologists realised the similar needs of dying patients with heart failure (HF). We examined recent trends in locations of deaths in these two patient populations to gain further insight.

METHODS

Complete population-level data were obtained from the Mortality Multiple Cause-of-Death Public Use Record from the National Center for Health Statistics database, from 2013 to 2017. Location of death was categorised as hospital, home, hospice facility or nursing facility. Demographic characteristics evaluated by place of death included age, sex, race, ethnicity, marital status and education, and a multivariable logistic regression analysis was performed to analyse possible associations.

RESULTS

Among 2 780 715 deaths from cancer, 27% occurred in-hospital and 14% in nursing facilities; while among 335 350 HF deaths, 27% occurred in-hospital and 30% in nursing facilities. Deaths occurred at hospice facilities in 14% of patients with cancer, compared with just 8.7% in HF (p=0.001). For both patients with HF and cancer, the proportion of at-home and in-hospice deaths increased significantly over time, with majority of deaths occurring at home. In both cancer and HF, patients of non-Hispanic ethnicity (cancer: OR 1.29, (1.27 to 1.31), HF: OR 1.14, (1.07 to 1.22)) and those with some college education (cancer: OR 1.10, (1.09 to 1.11); HF: OR 1.06, (1.04 to 1.09)) were significantly more likely to die in hospice.

CONCLUSION

Deaths in hospital or nursing facilities still account for nearly half of cancer or HF deaths. Although positive trends were seen with utilisation of hospice facilities in both groups, usage remains low and much remains to be achieved in both patient populations.

Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis

BACKGROUND

As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants.

METHODS

Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures.

RESULTS

Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths.

CONCLUSIONS

There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.

Place of Death for Individuals With Chronic Lung Disease: Trends and Associated Factors From 2003 to 2017 in the United States

BACKGROUND

Although chronic lung disease is a common cause of mortality, little is known about where individuals with chronic lung disease die.

RESEARCH QUESTION

The aim of this study was to determine the trends and factors associated with place of death among individuals with chronic lung disease.

STUDY DESIGN AND METHODS

This cross-sectional analysis of natural deaths was conducted by using the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research from 2003 to 2017 for which COPD, interstitial lung disease (ILD), or cystic fibrosis (CF) was the underlying cause. Place of death was categorized as hospital, home, nursing facility, hospice facility, and other.

RESULTS

From 2003 to 2017, more than 2.2. million deaths were primarily attributed to chronic lung disease (51.6% female, 92.4% white). Most were attributed to COPD (88.9%), followed by ILD (10.8.%), and CF (0.3%). Hospital and nursing facility deaths declined from 44.4% (n = 59,470) and 22.6% (n = 30,285) to 28.3% (n = 49,655) and 19.7% (n = 34,495), while home and hospice facility deaths increased from 23.3% (n = 31,296) and 0.1% (n = 192) to 34.7% (n = 60,851) and 9.0% (n = 15,861), respectively. Male sex, being married, and having some college education were associated with increased odds of home death, whereas non-white race and Hispanic ethnicity were associated with increased odds of hospital death. Compared with individuals with COPD, individuals with ILD and CF had increased odds of hospital death and reduced odds of home, nursing facility, or hospice facility death.

INTERPRETATION

Home deaths are rising among decedents from chronic lung disease, increasing the need for quality end-of-life care in this setting. Further research should explore the end-of-life needs and preferences of these patients and their caregivers, with particular attention paid to patients with ILD and CF who continue to have high rates of hospital death.

Intensity of care, expenditure, place and cause of death people with lung cancer in the year before their death: A French population based study

INTRODUCTION

Health care utilization of people with lung cancer (LC) the last year of life, their causes of death and place of death and the associated expenditure have been poorly described together. Then we conducted an observational study.

METHODS

People with LC covered by the French health Insurance general scheme (77% of the population) who died in 2015 were identified in the national health data system, together with their health care utilization and, in 95% of cases, their causes of death.

RESULTS

A total of 22,899 individuals were included (mean age: 68 years, SD±11.4), 72% of whom died in short-stay hospitals (SSH), 4% in hospital-at-home, 8% in Rehab hospital, 2% in skilled nursing homes and 14% at home. One-half of these people had also a chronic respiratory tract disease and 18% another cancer. Hospital palliative care (HPC) was identified for 65% of people, but for only 9% prior to their end-of-life stay. During the last month of life, 49% of people had two or more SSH stays, 15% were admitted to an intensive care unit, 23% received a chemotherapy session (13% during the last 14 days). The main cause of death was cancer for 92% of individuals (LC for 82%) The mean expenditure during the last year of life was €43,329 per individual.

DISCUSSION

This study indicates high rates of intensive care unit admissions and chemotherapy during the last month of life and a SSH hospital-centered management with intensive use of HPC mainly during the end-of-life stay.

Evaluating for disparities in place of death for head and neck cancer patients in the United States utilizing the CDC WONDER database

OBJECTIVE

Evaluate trends in place of death for patients with head and neck cancers (HNC) in the U.S. from 1999 to 2017 based on the CDC WONDER (Wide-ranging Online Data for Epidemiologic Research) database.

MATERIALS/METHODS

Using patient-level data from 2015 and aggregate data from 1999 to 2017, multivariable logistic regression analyses (MLR) were performed to evaluate for disparities in place of death.

RESULTS

We obtained aggregate data for 101,963 people who died of HNC between 1999 and 2017 (25.9% oral cavity, 24.6% oropharynx/pharynx, 0.4% nasopharynx, and 49.1% larynx/hypopharynx). Most were Caucasian (92.7%) and male (87.0%). Deaths at home or hospice increased over the study period (R² = 0.96, p < 0.05) from 29.2% in 1999 to 61.2% in 2017. On MLR of patient-level data from 2015, those who were single (ref), ages 85+ (OR 0.78; 95% CI: 0.68, 0.90), African American (OR 0.73; 95% CI: 0.65, 0.82), or Asian/Pacific Islanders (OR 0.66; 95% CI: 0.54, 0.81) were less likely to die at home or hospice. On MLR of the aggregate data (1999-2017), those who were female (OR 0.87; 95% CI: 0.83, 0.91) or ages 75-84 (OR 0.79; 95% CI: 0.76, 0.82) were also less likely to die at home or hospice. In both analyses, those who died from larynx/hypopharynx cancers were less likely to die at home or hospice.

CONCLUSIONS

HNC-related deaths at home or hospice increased between 1999 and 2017. Those who were single, female, African American, Asian/Pacific Islander, older (ages 75+), or those with larynx/hypopharynx cancers were less likely to die at home or hospice.

Health care utilization by men with prostate cancer during the year before their death: A 2015 population-based study

INTRODUCTION

To study the characteristics and health care utilization of men with prostate cancer (PCa) during their last year and last month of life, as these data have been rarely reported to date.

SUBJECTS AND METHOD

Men covered by the national health Insurance general scheme (77% of the French population) treated for PCa (2014-2015), who died in 2015 were identified in the national health data system, including reimbursed hospital and outpatient care, and their causes of death.

RESULTS

A total of 11,193 men (mean age: 81 years, SD: 9.6) were included. Almost 58% of these men died in a short-stay hospital (SSH), 4% died in hospital-at-home, 9% died in Rehab, 9% died in skilled nursing homes and 21% died at home. During the last year of life, almost all men were hospitalised at least once in SSH and 47% received hospital palliative care (HPC), immediately prior to death in 8% of cases. During the last month of life, 76% of men were hospitalised at least once in SSH, 43% attended an emergency department and 14% were admitted to intensive care, 7% received a chemotherapy session, and 24% received an antineoplastic agent dispensed by a retail pharmacy. Cancer was the main cause of death for 63% of men, corresponding to PCa in 40% of cases, and cardiovascular disease was the main cause of death for 13% of men with marked variations according to age, place of death, and use of HPC. The mean cost reimbursed per man during the last year of life was €38,750 (€48,601 including HPC).

CONCLUSIONS

In France, end-of-life management of men with PCa, regardless of the cause of death, is centered on SSH and HPC, essentially at the time of death. Certain indicators of end-of-life management were particular high.

LEVEL OF EVIDENCE

4.

Trends and Factors Associated with Place of Death for Individuals with Dementia in the United States

OBJECTIVES

To assess trends and factors associated with place of death among individuals with Alzheimer's disease-related dementias (ADRD).

DESIGN

Cross-sectional analysis.

SETTING

Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research, 2003-2017.

PARTICIPANTS

Natural deaths occurring between 2003 and 2017 for which ADRD was determined to be the underlying cause.

MEASUREMENTS

Place of death was categorized as hospital, home, nursing facility, hospice facility, and other. Aggregate data included age, race, Hispanic ethnicity, sex, urbanization, and census division. Individual-level predictors included age, race, Hispanic ethnicity, sex, marital status, and education.

RESULTS

From 2003 to 2017, nursing facility and hospital deaths declined from 65.7% and 12.7% to 55.0% and 8.0% while home and hospice facility deaths increased from 13.6% and .2% to 21.9% and 6.2%, respectively. Odds of hospital and hospice facility deaths declined with age while odds of nursing facility deaths increased with age. Male sex was associated with higher odds of hospital or hospice facility death and lower odds of home or nursing facility death. Nonwhite race, Hispanic ethnicity, and being married were associated with increased odds of hospital or home death and reduced odds of nursing facility death. More education was associated with higher odds of home or in a hospice facility death and reduced odds of death in a nursing facility or hospital. Significant disparities in place of death by urban-rural status were also noted.

CONCLUSION

As ADRD deaths at home increase, the need for caregiver support and home-based palliative care may become more critical. Further research should examine the care preferences and experiences of ADRD patients and caregivers, the financial impact of home death on families and insurers, and explore factors that may contribute to differences in actual and preferred place of death. J Am Geriatr Soc 68:250-255, 2020.

Place of death by region and urbanization among gynecologic cancer patients: 2006-2016

OBJECTIVE

To evaluate associations between US region of residence and urbanization and the place of death among women with gynecologic malignancies in the United States.

METHODS

A retrospective cross-sectional study was performed using publicly available death certificate data from the National Center for Health Statistics. All gynecologic cancer deaths were included from 2006 to 2016. Comparisons among categories were performed with a two-tailed chi-square test, with p-values <0.05 considered significant.

RESULTS

From 2006 to 2016, 328,026 women died from gynecologic malignancies in the US. Of these deaths, 40.1% (n = 134,333) occurred in the patient's home, 24.9%(n = 81,823) in the hospital, and 11.3% (37,188) in an inpatient hospice facility. Place of death varied by geographic region. The Northeast had the largest percentage of gynecologic cancer patients (31.3%) die as a hospital inpatient. The West had the highest percentage of deaths (49.3%) at home. Deaths in a hospice facility were the highest (14.1%) in the South. Place of death varied by urbanization; patients residing in large central metro or rural counties were the most likely to die during hospital admission (28.7% and 27.1%, respectively). Patients living in medium-sized metro areas were the least likely to die in hospitals (21.8%) and most likely to die in a hospice facility (14.3%). All comparisons were significant by study definition.

CONCLUSION

The place of death for patients with gynecologic malignancies varies by US region and urbanization. These disparities are multifactorial in nature, likely influenced by both sociodemographic factors and regional resource availability. In this study, however, rural and central metro areas are identified as regions that may benefit from further hospice development and advocacy.

Clustering of 27,525,663 Death Records from the United States Based on Health Conditions Associated with Death: An Example of big Health Data Exploration

Background: Insight into health conditions associated with death can inform healthcare policy. We aimed to cluster 27,525,663 deceased people based on the health conditions associated with death to study the associations between the health condition clusters, demographics, the recorded underlying cause and place of death. Methods: Data from all deaths in the United States registered between 2006 and 2016 from the National Vital Statistics System of the National Center for Health Statistics were analyzed. A self-organizing map (SOM) was used to create an ordered representation of the mortality data. Results: 16 clusters based on the health conditions associated with death were found showing significant differences in socio-demographics, place, and cause of death. Most people died at old age (73.1 (18.0) years) and had multiple health conditions. Chronic ischemic heart disease was the main cause of death. Most people died in the hospital or at home. Conclusions: The prevalence of multiple health conditions at death requires a shift from disease-oriented towards person-centred palliative care at the end of life, including timely advance care planning. Understanding differences in population-based patterns and clusters of end-of-life experiences is an important step toward developing a strategy for implementing population-based palliative care.