Open Access Research article

Study of recent and future trends in place of death in Belgium using death certificate data: a shift from hospitals to care homes

Dirk Houttekier1*, Joachim Cohen1, Johan Surkyn2 and Luc Deliens13

Author Affiliations

1 Vrije Universiteit Brussel, End-of-Life Care Research Group Ghent University & Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium

2 Vrije Universiteit Brussel, Interface demography, Pleinlaan 2, 1050 Brussels, Belgium

3 Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Palliative Care Center of Expertise, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands

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BMC Public Health 2011, 11:228  doi:10.1186/1471-2458-11-228

Published: 13 April 2011



Since most patients prefer out-of-hospital death, place of death can be considered an indicator of end-of-life care quality. The study of trends in place of death is necessary to examine causes of shifts, to evaluate efforts to alter place of death and develop future policies. This study aims to examine past trends and future projections of place of death.


Analysis of death certificates (decedents aged ≥ 1 year) in Belgium (Flanders and Brussels Capital region) 1998-2007. Trends in place of death were adjusted for cause of death, sociodemographic characteristics, environmental factors, numbers of hospital beds, and residential and skilled nursing beds in care homes. Future trends were based on age- and sex-specific mortality prognoses.


Hospital deaths decreased from 55.1% to 51.7% and care home deaths rose from 18.3% to 22.6%. The percentage of home deaths remained stable. The odds of dying in a care home versus hospital increased steadily and was 1.65 (95%CI:1.53-1.78) in 2007 compared to 1998. This increase could be attributed to the replacement of residential beds by skilled nursing beds. Continuation of these trends would result in the more than doubling of deaths in care homes and a decrease in deaths at home and in hospital by 2040.


Additional end-of-life care resources in care homes largely explain the decrease in hospital deaths. Care homes will become the main locus of end-of-life care in the future. Governments should provide sufficient skilled nursing resources in care homes to fulfil the end-of-life care preferences and needs of patients.