An aging population in combination with recent health reform has created the potential for increased pressure on families to care for the terminally ill at home. Moreover, it is known that up to 80% of terminally ill cancer patients actually prefer to die at home. This study found a significant trend towards increased out-of-hospital deaths, especially among individuals 85 years of age and older. Results indicate a need to address concerns of variable informal support and inadequate palliative care in the long-term care setting, such that the terminally ill can be cared for in the location that best meets their needs. As the national palliative care strategy is developed, policies should draw on the above findings and develop programs that meet patient needs, regardless of age, gender, demographic or socioeconomic status.

Background: An aging population, in combination with recent health reform, marked by decreased hospital stays and beds per capita, has created the potential for increased pressure on families to care for the terminally ill at home. Moreover, it is known that up to 80% of terminally ill cancer patients actually prefer to die at home. Yet, among patients referred to specialized palliative care programs, estimates of those dying at home remain between only 28% and 47%. Research on the reasons behind these trends is lacking. This paper has two objectives: 1) to characterize the yearly trend in the rate of out-of-hospital deaths among adult cancer patients in Nova Scotia between 1992 and 1997; and 2) to determine the predictors of observed trends in place of death.

Methods: The study was a retrospective, population-based investigation that used linked administrative databases to determine trends in the place of death of adult cancer patients. Cancer deaths were identified from death certificates and classified as "in-hospital" if they occurred in an acute-care hospital facility and "out-of-hospital" if they occurred in any other location, including home and long-term care centers. Death certificate data were subsequently linked to the Palliative Care Program database and administrative databases (e.g. Canadian Census) to aggregate individual level demographic data. Data analysis consisted of cross-tabulation and logistic regression to identify temporal changes in patterns and predictors of place of death. Predictors included in regression models were: year of death, gender, age, region of death, tumor group, receipt of palliative radiation, registration in a palliative care program, length of survival, place of residence and income quintile.

Results: Of the 13,937 study participants, 74% died in hospital and 26% died out of hospital. Over the five-year study period (1992 to 1997) there was a significant trend towards increased deaths out of hospital (from 20% to 31%), as confirmed by logistic regression. Individuals dying out of hospital were most likely to be female, over 75 years of age, registered in a Palliative Care Program, and to have survived 60 days post-diagnosis. Participants residing outside of metropolitan Halifax were less likely to die out of hospital, as were those who received palliative radiation. Tumor group, neighborhood income quintile, and urban versus rural residence were not found to be significant predictors of place of death.

Discussion: There was a significant trend towards increased out-of-hospital deaths over the study period. Individuals 85 years of age and older were more than twice as likely to die out of hospital compared to those aged less than 45. Elderly living at home have substantial variability in the presence of informal caregiver support. In the long-term care setting, there is growing recognition of the need to improve palliative care. Thus, with an aging population and given that most individuals with cancer prefer to die at home, there is a need to address these concerns and provide care to the terminally ill in the location that best meets their needs. As the national palliative care strategy is developed, policies should draw on the above findings and develop programs that meet patient needs, regardless of age, gender, demographic or socioeconomic status.

Reference: Burge, F., Lawson, B., and Johnston, G. "Trends in the place of death of cancer patients, 1992-1997." Canadian Medical Association Journal, 2003; 168(3): 265-269. [YEAR]

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