We found a shift in place of death among patients with cancer over the study period, from in hospital to outside of hospital. This shift may have had as much to do with how services are delivered in Nova Scotia as with personal choice. The proportion of deaths that occurred out of hospital increased from 19.9% to 30.2%. In addition, women, elderly people, those who survived longer after diagnosis and those referred to the Palliative Care Program were more likely to have died out of hospital. Although it is not possible to tell from administrative data whether the trend is a response to patient demand for care at home or a result of a reduction in hospital bed availability, the latter has been clearly documented.1,2,3,23
In addition, the availability of certain community-based services, namely home care24
and referral to palliative care programs,25
increased substantially during the study period.
In the United Kingdom the rate of home death among patients with cancer changed little from 1985 (27%) to 1994 (26.5%).9
In Belfast specifically, the rate of home death fell from 35% in 1977 to 28% in 1997.26
Concurrently, there was an increase in the rate of death in hospices in the United Kingdom.9
There are no freestanding hospices in Nova Scotia.
There are conflicting reports about the relation between age and location of death. Some investigators have reported that elderly people indicate a preference to die in hospital,27
whereas others have found that elderly people prefer to die at home.28
In our study, people 85 years of age or older were more than twice as likely to die out of hospital as those aged less than 45. Preference likely depends on personal experience, the course of the illness and the availability of local health care services.21
Our data are currently not in a form that allows separation of deaths in long term care facilities from true “in-home” deaths. In the case of sick elderly people who live at home, there is substantial variability in the presence of spouse or children caregivers.14,16,17,29
In the long-term care setting, there is growing recognition of the need to enhance palliative care to better meet the needs of residents. Clearly, with the recently documented increase of 41% in the number of Canadians aged 80 years or more,30
this issue will require greater exploration as specific programs are designed to meet the needs of elderly people.7
In our study, women were more likely than men to die out of hospital. This result is in keeping with the findings of Gilbar and Steiner.28
However, Higginson and colleagues9
found that women were less likely than men to die at home. There is a need to explore geographic and cultural differences between the sexes in the desire for home death.
Cancer patients in Nova Scotia who did not live in the metropolitan Halifax region were much less likely than those who lived in Halifax to die out of hospital. Perhaps an established “culture of caring” leads some communities to care for dying patients in hospital more than other communities. Provincial health reports indicate that Cape Breton has relatively higher volumes of patient-days per 1000 population and longer lengths of stay in acute care facilities than other regions in the province.23
However, this does not explain everything. The Annapolis Valley region, where cancer patients also had a lesser likelihood of dying out of hospital, has relatively fewer patient-days per 1000 and shorter lengths of stay in acute care facilities than Cape Breton does.23
A combination of factors may be contributing to the location of death, including how hospitals are utilized in different regions and the availability of community-based services. What part of a city or region people live in has been found by others to be predictive of location of death.26
Income has variably predicted location of death.15,26
In our study, income was a predictor in the univariate analysis only. Our data suggest that differences by income might be explained by “region” or “age” or both in multivariate analysis. Our finding that people with shorter survival after diagnosis were much more likely to die in hospital than those with longer survival is in keeping with previous reports.8
With limited time to effect interventions, it may be a challenge to establish the care preferences of such ill patients and their family and then organize this care in the home. Nevertheless, as hospitals continue to downsize, we may need to develop more responsive services to meet these “acute” needs.
People who received palliative radiation therapy may have had more complex symptom control needs as well as a greater likelihood of being in hospital for symptom control at the time of death than people who did not receive such therapy. Regarding palliative care programs, we suspect that both greater use of the Palliative Care Program by those desiring to die out of hospital and the focus of the program on keeping people with advanced cancer out of hospital resulted in the positive association between admission to such a program and out-of-hospital death.
Our data were restricted to available administrative sources. In the future we hope to add data on home care, referral to palliative care programs outside the Halifax region, long-term care, metastatic disease sites and patients' stated preferred location of death. In addition, research is needed to determine how home care, primary care and specialized palliative care services are used by those who die out of hospital.