Woody Allen famously said, “I’m not afraid of death, I just don’t want to be there when it happens.” Though most of us hesitate to explore the topic, dying is one of life’s inevitables and most of us would prefer a positive not a negative experience of it — whatever that might be. To better understand end-of-life issues, a team of Canadian researchers assessed the quality of cancer patients’ final days, in particular looking at palliative care. They discovered that, while the overall quality of death might be rated highly, those patients with the best experiences had not been hospitalized but had died at home.

Home, Hospice, or Hospital?

How does a scientist evaluate a person’s experience of death? For their new study, a team of researchers affiliated with the Princess Margaret Cancer Centre asked bereaved caregivers of 402 cancer patients to evaluate the patients’ final days using the Quality of Dying and Death (QODD) questionnaire. Eight to 10 months following the death, the caregivers filled in the QODD, and also reported on palliative care services received, bereavement distress, and place of death. All patients had died between 2005 and 2010 and were affiliated with a Toronto hospital. About one-third of the deaths occurred at home, 40 percent in an inpatient hospice/palliative care unit, and the remaining 28 percent in an acute care hospital.

How did the caregivers evaluate and rate patient deaths? Overall, more than a third (39 percent) rated quality of death as "good" to "almost perfect," while most (61 percent) ranked the death as "neither good nor bad." Generally, better scores were linked to older patients, those with high social support (not living alone), older caregiver age, greater length of relationship between the caregiver and patient, less caregiver bereavement distress, and home death. In fact, home deaths were associated not only with overall quality of death but also with better symptom control and death preparation.

Unfortunately, 15 percent of caregivers assessed symptom control as "terrible" to "poor," while 19 percent rated transcendence over death-related concerns (feeling at peace) as "terrible" to "poor." Late pain management or lack of specialized palliative care was associated with worse death preparation. Oddly, patients dying at home were more likely to receive the necessary palliative care than those dying either in a hospital or a hospice/palliative care unit.

No significant difference was found between a death in a hospice or palliative care setting and an acute care hospital. "You can have a good death in a hospice or a hospital setting when there is high quality palliative care," said Dr. Sarah Hales, coordinator of Psychiatry Services, Psychosocial Oncology & Palliative Care, Princess Margaret Cancer Centre. "Fear of dying is something almost every patient with advanced cancer or other life-threatening illness faces, and helping them, to achieve a ‘good death’ is an important goal of palliative care.”

 

Source: Hales S, Chiua A, Husain A, et al. The Quality of Dying and Death in Cancer and Its Relationship to Palliative Care and Place of Death. Journal of Pain and Symptom Management. 2014.