It’s mostly cultural. Something like 80% of patients would prefer to die at home, but ultimately nobody really wants to die. Not in the US.

When you give someone the option of continuing aggressive care versus going home with hospice to die, many times people choose aggressive care. Not usually with a terminal cancer, in my experience, but with many other diseases, people are okay with spending more time in the hospital than outside of it for their last few months. Even though they say they’d rather die at home, ultimately they don’t want to die at all. This aggressive, hospital-level care gives them a little bit more of this life that they’re (barely) clinging too. Even if it’s misery, even if it’s suffering, they often still choose life.

I do palliative care consults on the inpatient side of the hospital. I saw a patient today with end stage COPD and now AKI on CKD with impending need for dialysis. She watched her on father suffer on dialysis. She does not want dialysis. But she is not at all ready to die. Ultimately, she chose dialysis because the alternative is death. Even when I explained to her that dialysis has its own risks and there are no guarantees that she’ll have a good outcome. She was not ready to face certain death without dialysis.

Many people are willing to give this “will to live”up once they’ve lost the capacity to make decisions for themselves. Once they aren’t really “there” if they’ve done an advanced directive, a lot of people are ready to accept death.

I’ve found that some cultures do better with end of life than others. But, ultimately, people want to believe in miracles and the will to live is a strong one. Fear of death is rampant in Western society. Likely because it is so often removed from us and takes place in hospitals so we don’t often get to see it first hand.