Abstract
Background
Studies show that most patients with advanced cancer prefer to die at home. However, not all have equal chances and the evidence is unclear on whether dying at home is better. This study aims to determine the association between place of death, health services used, and pain, feeling at peace, and grief intensity.
Methods
Mortality follow-back study of 352 cancer patients who died in hospital (n = 177) or at home (n = 175) in London, UK. Bereaved relatives identified from death registrations completed a questionnaire including validated measures of patient’s pain and peace in the last week of life and their own grief intensity. We determined factors influencing death at home, and associations between place of death and pain, peace, and grief.
Results
Where people died was, for most (80 %), the place where they lived during their last week of life. Four factors explained >91 % of home deaths: patient’s preference, relative’s preference, home palliative care, or district/community nursing. The propensity of death at home also increased when the relative was aware of incurability and the patient discussed his/her preferences with family. Dying in hospital was associated with more hospital days, fewer general practitioner (GP) home visits, and fewer days taken off work by relatives. Adjusting for confounders, patients who died at home experienced similar pain levels but more peace in their last week of life (ordered log odds ratio 0.69, P = 0.007). Grief was less intense for their relatives than for those of patients who died in hospital (β, –0.15 around time of death and –0.14 at questionnaire completion, P = 0.02).
Conclusion
The study suggests that dying at home is better than hospital for peace and grief, but requires a discussion of preferences, GP home visits, and relatives to be given time off work.
Studies show that most patients with advanced cancer prefer to die at home. However, not all have equal chances and the evidence is unclear on whether dying at home is better. This study aims to determine the association between place of death, health services used, and pain, feeling at peace, and grief intensity.
Methods
Mortality follow-back study of 352 cancer patients who died in hospital (n = 177) or at home (n = 175) in London, UK. Bereaved relatives identified from death registrations completed a questionnaire including validated measures of patient’s pain and peace in the last week of life and their own grief intensity. We determined factors influencing death at home, and associations between place of death and pain, peace, and grief.
Results
Where people died was, for most (80 %), the place where they lived during their last week of life. Four factors explained >91 % of home deaths: patient’s preference, relative’s preference, home palliative care, or district/community nursing. The propensity of death at home also increased when the relative was aware of incurability and the patient discussed his/her preferences with family. Dying in hospital was associated with more hospital days, fewer general practitioner (GP) home visits, and fewer days taken off work by relatives. Adjusting for confounders, patients who died at home experienced similar pain levels but more peace in their last week of life (ordered log odds ratio 0.69, P = 0.007). Grief was less intense for their relatives than for those of patients who died in hospital (β, –0.15 around time of death and –0.14 at questionnaire completion, P = 0.02).
Conclusion
The study suggests that dying at home is better than hospital for peace and grief, but requires a discussion of preferences, GP home visits, and relatives to be given time off work.
| Original language | English |
|---|---|
| Article number | 235 |
| Journal | BMC Medicine |
| Volume | 13 |
| DOIs | |
| Publication status | Published - 2015 |
Bibliographical note
Trial registration: National Institute of Health Research (NIHR) Clinical Research Network Portfolio. UKCRN7041.Acknowledgements: We are most grateful to all the study participants. We thank Cicely Saunders International for the financial support needed to undertake this study including Barbara Gomes’ PhD Research Training Fellowship. The study involved many collaborators, to whom we are indebted: Professor Paul McCrone and Dr Sue Hall at King’s College London, the Department of Palliative Care at the Royal Marsden Hospital (Dr Julia Riley, Meena Valambhia, among others); Dr Elizabeth Davies and Dr Peter Madden at the Thames Cancer Registry; Professor Mike Richards and Tessa Ing on behalf of the Department of Health; the ONS Health Analysis team (Myer Glickman, Peter Davies, Stephen Rowlands, Justine Pooley); the Islington, Westminster, Bromley, and Sutton & Merton Primary Care Trusts (Nada Lemic, Sarah Price, Clare Henderson, Jacqui Lindo, Ursula Daee, end-of-life care groups, communication teams); the South East London Cancer Research Network (Kerry Hylands for data entry and governance advice). We thank the members of the project steering group, patient/family representatives (Nell Dunn, Kirstie Newson), the international scientific expert panel from Cicely Saunders International, Brenda Ferns, and external advisors (Dr Anita Patel, Professor Colin Murray Parkes, Dr Joana Cadima, Dr Massimo Costantini). We also thank the local services that helped us understand better the findings, including staff at St. Christopher’s Hospice, the ELiPSe team, and colleagues at King’s College London (Claudia Bausewein, Despina Anagnostou, Emma Murphy, Fliss Murtagh, Gao Wei, Lucy Selman, Marjolein Gysels, Sian Best, Thomas Osborne and Vera Sarmento, among others). Thanks to the Calouste Gulbenkian Foundation for patience and encouragement. We are also grateful to Professor Gunn Grande and Professor Christine Ingleton for their review and insightful comments.
