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By Phillip Reese,
Kaiser Health News
The COVID-19 pandemic has spurred a surge in the proportion of Californians who are dying at home rather than in a hospital or nursing home, accelerating a slow-but-steady rise that dates back at least two decades.
The recent upsurge in at-home deaths started in 2020, the first year of the pandemic, and the rate has continued to climb, outlasting the rigid lockdowns at hospitals and nursing homes that might help explain the initial shift.
Nearly 40% of deaths in California during the first 10 months of 2022 took place at home, up from about 36% for all of 2019, according to death certificate data from the California Department of Public Health. By comparison, U.S. Centers for Disease Control and Prevention data shows that about 26% of Californians died at home in 1999, the earliest year for which statistics on at-home deaths is accessible in the agency’s public database.
The trend is amplified among California residents with serious chronic conditions.
About 55% of Californians who died of cancer did so at home during the first 10 months of 2022, compared to 50% in 2019 and 44% in 1999. About 43% of Californians who died of Alzheimer’s disease in the first 10 months of 2022 did so at home, compared to 34% in 2019 and nearly 16% in 1999.
Nationwide, the share of deaths occurring at home also jumped in 2020, to 33%, then rose to nearly 34% in 2021. Nationwide data for 2022 is not yet available.
The pandemic’s early, deadly sweep across California does not in itself explain the increase in at-home death rates; the vast majority of people who have died from coronavirus-related causes did so in a hospital or nursing home. Instead, medical experts said, the surge — at least initially — appears to coincide with sweeping policy changes in hospitals and nursing homes as caregivers struggled to contain a virus both virulent and, at the time, little understood.
The sweeping bans on in-person visitation in hospitals and nursing homes, even to the bedsides of dying patients, created an agonizing situation for families. Many chose to move a loved one back home.
“It was devastating to have Mom in a nursing home and dying,” said Barbara Karnes, a registered nurse who has written extensively about end-of-life care, “and the only way you can see Mom is through the window.”
At the same time, fears of exposure led many people to avoid hospitals in the first years of the pandemic, in some cases neglecting treatment for other serious conditions. That, too, is thought to have contributed to the rise in at-home deaths.
Those who specialize in end-of-life care say it is no surprise the trend has continued even as visitation policies have eased. More people simply want to die in a comfortable, familiar place, they said, even if it means not fighting for every second of life with medical interventions.
“Whenever I ask, ‘Where do you want to be when you breathe your last breath? Or when your heart beats its last beat?’ no one ever says, ‘Oh, I want to be in the ICU,’ or ‘Oh, I want to be in the hospital,’ or ‘I want to be in a skilled nursing facility.’” said John Tastad, coordinator for the advance care planning program at Sharp HealthCare in San Diego. “They all say, ‘I want to be at home.’”
At the same time, the physicians who specialize in the diseases that tend to kill Americans, such as cancer and heart disease, have become more accepting of discussing home hospice as an option if the treatment alternatives likely mean painful sacrifices in quality of life.
“There’s been a little bit of a culture change,” said Dr. Pouria Kashkouli, associate medical director for hospice at UC Davis Health, “where maybe oncologists, pulmonologists, congestive heart failure physicians are referring patients to palliative care earlier to help with symptom management, advanced care planning.”
The trends have created a booming industry.
In 2021, the California Department of Health Care Access and Information listed 1,692 licensed hospice agencies in its tracking database, a leap from the 175 agencies it listed in 2002.
That much growth — and the money behind it — has sometimes led to problems.
A 2020 investigation by the Los Angeles Times found that fraud and quality-of-care issues were common in California’s hospice industry, a conclusion bolstered by a subsequent state audit. Gov. Gavin Newsom signed a bill in 2021 that placed a temporary moratorium on most new hospice licenses and sought to rein in questionable kickbacks to doctors and agencies.
When done correctly, though, home hospice can be a comfort to families and patients. Hospice typically lasts anywhere from a few days to a few months, and while services vary, many agencies provide regular visits from nurses, health aides, social workers and spiritual advisers.
Most people using hospice are insured through the federal Medicare program. The amount Medicare pays varies by region but is usually around $200 to $300 a day, said Dr. Kai Romero, chief medical officer at the nonprofit Hospice by the Bay.
To find quality end-of-life care, Andrea Sankar, a professor at Detroit’s Wayne State University and author of “Dying at Home: A Family Guide for Caregiving,” recommends seeking out nonprofit providers and having a list of questions prepared.
Those questins include:
While hospice providers offer crucial guidance and support, families need to be prepared to shoulder the bulk of the caregiving.
“It really takes a pretty evolved family system,” Tastad said, “to be able to rally to meet all of the needs.”
The proportion of Californians choosing to die at home, meanwhile, is expected to keep climbing, several end-of-life experts said. They citied various factors for the projected increase:
Medical advances will make it easier for patients to receive pain management and other palliative care at home, they said. Telemedicine will make it easier for patients to consult doctors from home.
And two powerful forces in American health care — insurance companies and the federal government — increasingly see dying at home as an affordable alternative to lengthy hospital stays.
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.
Kaiser Health News is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at Kaiser Family Foundation. KFF is an endowed nonprofit organization providing information on health issues to the nation.
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