1. Deepthi Mohankumar,PhD Postdoctoral Fellow Faculty of Nursing, University of Alberta

2.  Gender  Age  Socioeconomic status  Living arrangements  Feasibility of a good home death, functional status  Availability of nursing homes, hospice facilities  Preference for location of death

3.  Decrease in hospital deaths in the 1980s – 41% to 29%  Reverse trend in the 1990s – 30% to 60%  Family influences – fewer caregivers  State influences

4.  Most frequent response to critical illness is to stave off death – the medical model  25% of all hospitalized patients are treated in cardiac or intensive care units before death.  Influence of the Patient Self-Determination Act (PSDA)  Influence of the hospice movement

5.  Unequal distribution of ability to die at home.  Patients with informal caregiver support are more likely to die at home and access palliative home care.  Older individuals are less likely to die at home.  Women are less likely to die at home.  Individuals with cancer in higher socioeconomic groups are more likely to die at home.

6.  Living in a state with greater support for home and community based services is an indicator.  Effect of Medicaid (Muramatsu et al., 2008).  Higher prevalence of in-patient hospice deaths in terminally ill individuals, primarily cancer (Tang et al., 2004)  Distance from home (greater for individuals younger than 65)

7.  National Mortality Followback Survey- 60% of deaths occurred in hospitals, 20% in homes or nursing homes (Weitzen et al., 2003)  African-Americans, less educated, enrollment in an HMO- Predictors of hospital deaths.  Functional decline in the last 5 months of life associated with at home deaths.  PACE participants (45%) die at home (2002), 21% in hospitals vs. 53% Medicare beneficiaries

8.  Ethnic differences exist – Elderly minorities are more likely to die in inpatient settings.  Multilevel analysis with death certificates, county and state data (Gruneir et al.,2007): Disproportionate home deaths in Whites, higher education, greater access to community and social support, cancer deaths.

9.  Research emphasis on demographic differences.  Overall hospital versus home versus nursing home changes are low over the last twenty years.  Preference versus actual location of death- characteristics of the local health care system has the most influence – availability of beds, closeness of hospice.

10.  Maintenance in funding for the Medicaid Follow the Money program through 2016 to transition individuals from nursing homes to communities.  Community First Choice Programs  Cash benefit to individuals using community based services for ADLs.  Independence at Home program for Medicare.  No end-of-life specifics.