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Individual, clinical and system factors associated with the place of death: A linked national database study

Bajpai, Ram; Low, Chan Kee; Ho, Andy Hau Yan; Wu, Huei Yaw; Car, Josip; Tan, Woan Shin

Individual, clinical and system factors associated with the place of death: A linked national database study Thumbnail


Chan Kee Low

Andy Hau Yan Ho

Huei Yaw Wu

Josip Car

Woan Shin Tan


Many middle- and high-income countries face the challenge of meeting preferences for home deaths. A better understanding of associated factors could support the design and implementation of policies and practices to enable dying at home. This study aims to identify factors associated with the place of death in Singapore, a country with a strong sense of filial piety.

A retrospective cohort of 62,951 individuals (=21 years old) who had died from chronic diseases in Singapore between 2012–2015 was obtained. Home death was defined as a death that occurred in a private residence whereas non-home deaths occurred in hospitals, nursing homes, hospices and other locations. Data were obtained by extracting and linking data from five different databases. Hierarchical multivariable logistic regression models were used to examine the effects of individual, clinical and system factors sequentially.

Twenty-eight percent of deaths occurred at home. Factors associated with home death included being 85 years old or older (OR 4.45, 95% CI 3.55–5.59), being female (OR 1.21, 95% CI 1.16–1.25), and belonging to Malay ethnicity (OR 1.91, 95% CI 1.82–2.01). Compared to malignant neoplasm, deaths as a result of diabetes mellitus (OR 1.93, 95% CI 1.69–2.20), and cerebrovascular diseases (OR 1.28, 95% CI 1.19–1.36) were also associated with a higher likelihood of home death. Independently, receiving home palliative care (OR 3.45, 95% CI 3.26–3.66) and having a documented home death preference (OR 5.08, 95% CI 3.96–6.51) raised the odds of home deaths but being admitted to acute hospitals near the end-of-life was associated with lower odds (OR 0.92, 95% CI 0.90–0.94).

Aside from cultural and clinical factors, system-based factors including access to home palliative care and discussion and documentation of preferences were found to influence the likelihood of home deaths. Increasing home palliative care capacity and promoting advance care planning could facilitate home deaths if this is the desired option of patients.

Journal Article Type Article
Acceptance Date Apr 5, 2019
Publication Date Apr 18, 2019
Journal PLoS One
Print ISSN 1932-6203
Publisher Public Library of Science (PLoS)
Peer Reviewed Peer Reviewed
Volume 14
Issue 4
Article Number e0215566
Keywords palliative care; Singapore; Malay people; Hospitals; Ethnic epidemiology; Nursing homes; Health care policy; Neoplasms
Publisher URL