Quality of care at the end of life is strongly correlated with where patients die. This review discusses the influence of patient and health system variables affecting access to common venues of death-the acute care hospital, the nursing home, and home-with or without hospice. Access to care is considered in terms of a flow model, wherein pressure gradients push patients toward care in certain venues and away from alternatives. Dynamic interactions between patient-specific variables and health care system variables influence the nature of patient flow, moving patients toward certain terminal venues of care and away from others. Efforts to improve quality of care at the end of life must be cognizant of these effects and should work to adjust patterns of flow in more favorable directions.
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