Place of Death Inpatient units have a role Sir Dr Tiernan et al have contributed to the literature with the prospective study of preferred place of death in a palliative population.1 There continues to be pressure that suggests home is the best place to die. Both patient and carer issues are relevant in the ultimate decision about place of care. Further, preference may change over the course of someones life-limiting illness as circumstances change, a factor that would strengthen subsequent studies. The decision to die at home is not just about the resources allocated to palliative care in the community.2 Economic arguments that suggest community care is less expensive tend to ignore the complete costs of caring especially to unpaid carers.3 Although studies have looked at preference for place of death, few highlight that for an appreciable group of patients and carers, inpatient units may be the preferred place to die. These choices need to be supported. Patient preference for death in an inpatient unit in a comprehensive regional palliative service | | New referrals | Deaths - total | Deaths - total Explicit preference for hospital* | Inpatient deaths | Deaths in the community | Total | Known patient preference | Known to be acceptable to patient | Acceptable to patient* | 1997 | 432 | 377 | 38% 144/377 | 68% 257/377 | 70% 180/257 | 80% 144/180 | 56% 100-((257-144)/257) | 32% 120/377 | 1998 | 576 | 383 | 37% 140/383 | 64% 246/383 | 71% 175/246 | 80% 140/175 | 57% 100-((246-140)/246) | 36% 137/383 | 1999 | 596 | 442 | 23% 100/442 | 70% 310/442 | 38% 119/310 | 84% 100/119 | 32% 100-((310-100)/310) | 30% 132/442 | Total | 1604 | 1202 | 32% 384/1202 | 68% 813/1202 | 58% 474/813 | 81% 384/474 | 47% 100-((813-384)/813) | 32% 389/1202 |
We report data from a similar service (550+ referrals per year, servicing a population of 300 000 people in a 4000 km2 area, median time from referral to death 5.5 months) collected over a 3 year period at a later time in the disease trajectory. This interdisciplinary, regional palliative team serves both metro-politan and rural areas in the west of Sydney, Australia. The service includes hospital inpatient and consultative care, outpatient clinics and community care. Since 1996, each month, we reviewed all deaths in an area-wide meeting. We recorded at the end of life the team members explicit knowledge of the patients and separately the carers wishes as to where care should be for the terminal phase of life. In the data presented, if the patients preferences were not known, it is assumed that an inpatient facility would not have been the preferred place to die. Of those patients who died in an inpatient facility, where a preference for place of death was known by staff, 4/5 were satisfied with their site of death. Of all people who died in hospital, including where preferences may not have been known, 1/2 were happy with an inpatient facility as their site of death despite the availability of community support. Of all people who died in the 3 years, at least 1/3 were happy with hospital as the place of death. (See table) Taking the worst case and assuming that only those with an explicit preference for inpatient care would find it acceptable, in the paper by Tiernan, 27/191 (14%) had an explicit preference for care in an inpatient unit. In the paper by Steinhauser exploring important issues at the end of life for cancer patients, only 35% of people expressed a wish to die at home.4 Inpatient units are acceptable to many patients and their carers as the place to die. We must carefully examine statements such as if enough resources are committed to community care, then everyone will want to die at home. This is about choice and ensuring that resources enable people to exercise their choice for place of care. Measures of good service delivery should reflect the complexity of these choices, not simply crude community death rates. 1DC Currow, 2MA Noel, 3KA Sullivan 1Professor of Palliative and Supportive Services, Flinders University, Adelaide, Australia 2Area Director Palliative Services, Wentworth Area Health Service, Sydney, Australia 3Clinical Nurse Consultant, Wentworth Area Palliative Services, Sydney, Australia Correspondence: David Currow, 700 Goodwood Road, Daw Park, South Australia, Australia 5041. Telephone: (+61 8) 8275 1871. Fax: (+61 8) 8374 4018. Email: [email protected]. References - Teirnan E, Connor MO, Kearney PM, OSiorain. A prospective study of preferred versus actual place of death among patients referred to a palliative care home-care service. IMJ 2002;95:
- Grande GE, Todd CJ, Barclay SIG, Farquhar MC. Does hospital at home for palliative care facilitate death at home? Randomised controlled trial. BMJ 1999; 319: 1472-1475.
- Van den Eynden B, Hermann I, Schrijvers D, Van Royen P, Maes R, Vermeulen L, Herweyers K, Smits W, Verhoeven A, Clara R, Denekens J. Factors determining the place of palliative care and death of cancer patients. Support Care Cancer 2000; 8:59-64.
- Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky J. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284:2476-2482.
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