Place of death

Dying at ‘home’—one’s own home or a residential aged care facility—is considered a positive outcome of quality palliative care. [1] Many older people want a peaceful, pain-free death in their home, rather than in an emergency department or hospital ward. [2, 3] Although an acute care transfer may be necessary near the end of life due to a medical crisis (i.e., a cardiovascular event, a fall, an infection, or an uncontrolled pain or symptom burden), it may be more appropriate and in keeping with a person’s wishes, to be supported to die in the familiar home setting. [2, 3] 

This evidence theme on place of death is a summary of one of the key topics identified by a scoping review of the palliative care research in the setting of aged care. If you need more specific or comprehensive information on this topic, try using the PubMed search provided below.  

We identified eight systematic reviews that describe factors associated with an older aged care recipient dying in a particular location which may or may not be their preferred place of death.  

Preferred place of death

Evidence suggests that when a person dies in their preferred place, their satisfaction with end-of-life care is improved. [2] However, where someone dies is influenced by a wide range of factors. These include the level of social support available to them, access to healthcare, and the nature of the person’s illness. [2] Although a large proportion (around 82%) of older people express a preference for dying in the home setting, this is not always achieved. [2, 3] Additionally, there are conflicting findings on where people with dementia are more likely to die [4, 5], although one review suggests many do not eventually die at home. [6]  

Dying in hospital

The available research suggests a hospital death may be more likely if:   

• A person with dementia is male, older, and has good access to hospital services [5] 
• The dying person lives on their own or has a terminal condition other than cancer [2] 
• Nursing home residents have less access to nursing [7] or general practitioner care [3] near the end of life  
• An advance care plan is not in place communicating preferences for end-of-life care [3] 
• Direct care staff lack knowledge around the natural signs of approaching death and how to make a person comfortable at the end of life. [3] 

While being hospitalised at the end of life is often appropriate care, residential aged care staff should work to avoid transferring a person who would prefer to die in the home setting. [7]  

Dying in a home setting

The evidence suggests people are more likely to die in their own home or residential care facility if:  

• They have a preference for a home death [2] 
• Cancer is the cause of death rather than some other cause [2] 
• They do not have access to acute care facilities, for example, people living in rural and remote parts of Australia [1]  
• They are supported to die in the home setting by the involvement of specialist health practitioners in their care [6, 8] or a multidisciplinary palliative care team [2] 
• They receive an early, rather than late, referral to a palliative care service [2] 
• There is an advance care plan or ‘do not resuscitate’ order in place that details preferred place of death [2, 3] 
• An informal caregiver is present, particularly one with a strong ability to cope, manage medications and symptoms, and support the person’s wish to die at home [2, 6] 
• A person with dementia living at home has strong social networks and receives personal and nursing care support from home care providers. [6] 

Many of the reviews covered in this evidence theme describe the available research on place of death as being scarce and of low quality, especially when focused on people living with dementia. [5, 6] Reasons provided include small numbers of participants, little information about interventions, and potentially important differences between the settings researched. [2, 3, 8] This may reduce the degree of certainty we have about some of the factors influencing place of death.

• Increase personal understanding of the signs that a person may be nearing the end of their life. 
• Speak to care recipients and encourage them to consider developing an advance care plan/advance care directive that includes information on where the person would like to die.   
• Encourage care recipients to have regular conversations with their family, friends, carers, and aged care staff about wishes for end-of-life care.   
• Be aware of each person’s place of death preference or where you may find this information when needed. 
• Be prepared to support place of death preferences and have open discussions about what might make it challenging to fulfil a particular wish. 
• Understand the factors that may influence a person’s wishes for a specific place of death – these may include improved knowledge of estate planning.  
• Ensure people nearing the end of life have good access to healthcare professionals and specialist palliative care expertise, if required. 

• Support staff to develop their skills in discussing end of life preferences with care recipients and their families, and to develop the confidence to advocate for non-hospital care when this in the person's best interest when at end of life. 
• Provide ongoing education around the need to have ‘difficult’ conversations; this may include discussions on the development of advance care plans. 
• Ensure aged care recipients have access to high quality palliative care services as early as possible in the course of a life-limiting illness.  
• Support healthcare professionals and multidisciplinary palliative care teams to work within the residential aged care setting to provide direct care or train facility staff in end-of-life care.

1. Rainsford S, MacLeod RD, Glasgow NJ. Place of death in rural palliative care: A systematic review. Palliat Med. 2016;30(8):745-763.  
2. Costa V, Earle CC, Esplen MJ, Fowler R, Goldman R, Grossman D, et al. The determinants of home and nursing home death: A systematic review and meta-analysis. BMC Palliat Care. 2016;15:8.  
3. Spacey A, Scammell J, Board M, Porter S. End-of-life care in UK care homes: A systematic review of the literature. J Res Nurs. 2018;23(2-3):180-200.  
4. Hoffmann F, Strautmann A, Allers K. Hospitalization at the end of life among nursing home residents with dementia: A systematic review. BMC Palliat Care. 2019;18(1):77.  
5. Badrakalimuthu V, Barclay S. Do people with dementia die at their preferred location of death? A systematic literature review and narrative synthesis. Age Ageing. 2014;43(1):13-19.  
6. Mogan C, Lloyd-Williams M, Dening KH, Dowrick C. The facilitators and challenges of dying at home with dementia: A narrative synthesis. Palliat Med. 2018;32(6):1042-1054.  
7. Allers K, Hoffmann F, Schnakenberg R. Hospitalizations of nursing home residents at the end of life: A systematic review. Palliat Med. 2019;33(10):1282-1298.  
8. Buck D, Tucker S, Roe B, Hughes J, Challis D. Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis. J Adv Nurs. 2022;78(3):666-697.