Where people die is often important to them and their families, as well as being important for planning health care services. Most people want to die at home, but most die in hospital.

While the trends have been studied in cancer, other diseases, such as respiratory, are rarely looked at even though they are common and increasing causes of death. In a new study, published in the journal BMC Medicine, researchers from King’s College London’s Cicely Saunders Institute studied a national data set of all deaths from two common groups of respiratory diseases – Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Pulmonary Diseases (IPD), covering 380,232 people over 14 years.

Both conditions result in a high use of hospital services, especially among people in advanced stages. This leads to high healthcare costs. In the UK in 2010, for example, it is estimated that IPD cost £16.2 million per year in hospitalisations. The NHS spends more than £810 million annually managing COPD, with hospital stays accounting for around £250 million per year.

In this study, which was funded by the National Institute for Health Research, the team looked at the impact of a national end of life care strategy to reduce deaths in hospital.

The main findings included:

• Hospital deaths from COPD and IPD fell by 3–6% in the eight years following the introduction of the End of Life Care Strategy. This reversed previous trends.
However, those patients with more than one disease or disorder (multimorbidity) did not show a fall in hospital deaths.
• People with three or more different diseases, as well as their COPD or IPD, were over a third more likely to die in hospital than those who did not.
• Deprivation also independently increased the chances of dying in hospital.
• London had the highest hospital deaths, and the South–West and South East Coast regions had lower hospital deaths than most other regions. Living in urban areas increased the chances of hospital death.
• Surprisingly for people with COPD, being single, widowed or divorced was associated with reduced chances of dying in hospital. Researchers suggest that this may show that when family members are present, they do not know what to do when breathlessness escalates which increases the chance of patients being admitted to hospitals.

Lead author, Professor Irene Higginson from King’s College London said: 'Understanding which factors affect place of death is vital for planning service and improving care, especially given our ageing population, rising chronic diseases worldwide and the high costs of hospital admissions.

'Our results show that while the End of Life Care Strategy may have helped to move some deaths out of hospital for people with respiratory disease, it still misses important groups.

'It was particularly concerning that there was no fall in hospital deaths for people with multimorbidity, and that the disparity widened over time. In the UK, the number of people with three or more long–term conditions is predicted to rise from 1.9 million in 2008 to 2.9 million in 2018, requiring a major increase in healthcare expenditure.

'It is therefore essential that future strategies for end of life and palliative care directly target those at highest risk, especially with multimorbidity, and in deprived areas and cities, and this may require different approaches.'