Twentieth-century social and health-care influences on location of death in Canada.

Providing the right care, in the right place, to dying persons is hampered by a lack of understanding of where death and dying normally take place and ignorance about what influences location of death. This paper reports the findings of a multidisciplinary historical investigation of 20th-century influences on location of death in Canada. It builds on a study that found a hospitalization-of-death trend in Canada over much of the 20th century but a reduction in hospital deaths beginning in 1994. This study found 2 key influences on location of death: (1) health-care and health-system developments that consolidated care in hospitals while also raising and sustaining public expectations of beneficial if not curative hospital care--the rising hospital-death rate throughout the 20th century can thus be considered an outcome of the shift of illness care from the home to the hospital; and (2) reduced availability of home-based caregivers. A number of developments limited the availability of home care for chronically ill and terminally ill persons, including the increased participation of women in the workforce and the shift in nursing from private home duty to hospitals. Although some health and social support for home care has developed recently, this support clearly does not match that for hospital care. These findings indicate that location of death is an important focal point for studying and planning improvements in end-of-life care.