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RESEARCH: Barbara Gomes and Irene J Higginson Factors influencing death at home in terminally ill patients with cancer: systematic review BMJ 2006; 332: 515-521 [Abstract] [Full text]

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But the NHS doesn't always support death at home!

Anonymous doctor   (6 March 2006)

Factors that influence where patients with cancer die in Cuba

Alfredo A Espinosa-Roca, Alfredo D. Espinosa-Brito, Eduardo Fernández-Casteleiro, Teresita Sabatés-Llerandi   (7 March 2006)

But the NHS doesn't always support death at home! 6 March 2006
Anonymous doctor, GP name and address supplied Send response to journal: Re: But the NHS doesn't always support death at home!	While death at home may be preferred by patients and their relatives, it has resource implication for NHS managers. In a recent case an NHS employee was reprimanded for encouraging discharge from hospital to ensure death occurred in the patient’s preferred venue. Though Gold Standards of care call for minimisation of the number of involved health care professionals, the individual (nurse) has been threatened with disciplinary action for giving a higher standard of care than that she was contracted to provide. This has major implications for Palliative care in the NHS under the New General Practice Contract. Are GPs entitled to give palliative care outside contracted hours? Should palliative care become a service attracting extra-contractual payments? Patients’ preferences may be important – but those of NHS managers have more clout in the real world! Competing interests: None declared
Factors that influence where patients with cancer die in Cuba 7 March 2006
Alfredo A Espinosa-Roca, Coordinator of Palliative Care Program, Cienfuegos City Municipal Health Division of Cienfuegos, 55 100, Alfredo D. Espinosa-Brito, Eduardo Fernández-Casteleiro, Teresita Sabatés-Llerandi Send response to journal: Re: Factors that influence where patients with cancer die in Cuba	Dear Editor: As Gomes and Higginson suggested, identification of factors that influence where terminally ill patients with cancer die is complicated. (1) In 1981-1982, a study of 13 105 adult (15 years and over) deaths in three different Cuban provinces was carried out by our group. It was found that only 27.0% of adult deaths due to malignant tumours ocurred outside hospitals in Ciudad de La Habana, a western province which includes our capital city; but 60,2% in Cienfuegos, in the center and southern part of the island; and 58.2% in Las Tunas, in the eastern side of the country. At that time, persons who died at home due to cancer: a) were older than hospital ones; b) were less frequent in urban areas; and c) there were no differences by sex. (2) In a second research, we studied adult mortality in the same three Cuban provinces, during 10 years, since 1990 to 1999. In that period, deaths due to malignant tumours were 36 999 in Ciudad de La Habana, (19.3% of all deaths); 5 269 in Cienfuegos (19.9%); and 5 820 in Las Tunas (21.6%. The mean ages were 67.9±14.6 years, 67,9±15.9 years and 66.1±16.6 years, respectively. In spite of very similar proportion of deaths and mean ages, the place of death where patients with cancer died among these provinces, were not so, again. Only 28.3% died at home in Ciudad de La Habana. This proportion increased to 61.8% in Cienfuegos, and was 34.4% of deaths due to cancer occurred in Las Tunas. (3) Looking for the causes of so high persistent percentages of patients with cancer who die at home in our region (Cienfuegos), we recently carried out another research in Cienfuegos City, the capital of our province (unpublished data). The relatives or proxys of 226 adults (15 years and over) who lived in this city, and died in 2003, were interviewed. They were a randomized sample of all adult deaths ocurred in this location, that year. Of 171 that were classified as terminally ill patients, 91 (53.2%) died at home. According to the answers, in 57.6% of the cases, this was because patients and/or relatives own decisions. Since the last years of the past decade, we implemented and conducted a comprehensive program of palliative care at primary level in Cienfuegos. So, we assume that persistence of high proportions of deaths at home in cancer patients in Cienfuegos could be related to this new service. (4) Even in a highly organized public National Health System such as ours is - universal, accesible, equitable, and free for all-, it appears to effectively work to go outside ordinary channels to look for local answers to specific conditions, as those described here. (5) Sincerely, Alfredo A. Espinosa-Roca MD, Prof. Alfredo D. Espinosa-Brito, MD, PhD, Eduardo Fernández-Casteleiro, MD, Teresita Sabatés-Llerandi, MD. Municipal Health Division of Cienfuegos, Ave 56 No. 2917 altos, Cienfuegos 55100, Cuba. E-mail: espinosa@perla.inf.cu Internal Medicine Department and Oncology Department, Teaching Hospital "Dr. Gustavo Aldereguia Lima", Cienfuegos. Ave 5 de Septiembre and Calle 51A, Cienfuegos 55100, Cuba. E-mail: espinosa@gal.sld.cu References 1. Gomes B, Higginson IJ. Factors influencing death at home in terminally ill patients with cancer: systematic review. BMJ 2006;332:515-521 2. Espinosa A., Diez E, González E, Santos M, Adultos fallecidos en tres provincias cubanas (1981-1982). Algunos factores relacionados con el lugar donde ocurrió la muerte. Rev Cub Salud Pública 1989;15:245-258. 3. Espinosa A, Quintero Y, Cutiño Y, Romero AJ, Bernal JL. Mortalidad del adulto en tres provincias cubanas In Iñiguez L, Pérez OE. Heterogeneidad social en la Cuba actual. Ciudad de La Habana: Centro de Estudio de Salud y Bienestar Humano. Universidad de La Habana 2004:163-194. 4. Espinosa AA, Romero AJ, Misas M, Fresneda O. Asistencia al enfermo terminal en la atención primaria de salud. Rev Finlay 2005;10 (número especial):133-143 5. Murray SA, Boyd K, Thomas K, Higginson IJ. Developing primary palliative care (editorial). BMJ 2004;329:1056-1057 Competing interests: None declared