Is dying in hospital better than home in incurable cancer and what factors influence this? A population-based study

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.

Trial registration: National Institute of Health Research (NIHR) Clinical Research Network Portfolio. UKCRN7041.

Fig. 1

Permanence in place versus timing of last transition by place of death. The figure shows how long the patients were in the place where they died. Numbers and percentages by place of death are placed backwards from death according to the time period when the last transition happened. For example, 75 out of 168 people who died at home (45 %) were at home for 6 months or more (with no transition). Two (1 %) went home in their last 24 hours of life. Eleven patients had missing data: seven home deaths, four hospital deaths (including two people who gave inconsistent information).

Fig. 2

Unadjusted and adjusted associations with death at home. ^a Factors identified through bivariate analysis (P <0.05); ^b Factors retained in the final multivariate model (P <0.05) except for those in italic, which show the strongest unadjusted associations but due to near-zero cell frequencies and multicollinearity with place of death could not be included in the logistic regression model

Fig. 3

Five factors independently associated with death at home rather than in hospital. Factors retained in the final multivariate model (P <0.050). The dots present adjusted odds ratios and horizontal lines indicate 95 % confidence intervals. The model was statistically reliable [Hosmer and Lemeshow χ²(8,263) = 4.721, P = 0.787]; it correctly classified 82 % of the cases (persons who died at home) and 79 % of the controls (persons who died in hospital)