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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province (unpublished data).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
Competing interests:
No competing interests
07 March 2006
Alfredo A Espinosa-Roca
Coordinator of Palliative Care Program, Cienfuegos City
Alfredo D. Espinosa-Brito, Eduardo Fernández-Casteleiro, Teresita Sabatés-Llerandi
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!
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
Competing interests: No competing interests