Where do cancer patients die? Ten-year trends in the place of death of cancer patients in England

Abstract

Although studies have found that 50–70% of cancer patients would prefer to die at home, there has been a trend towards the hospitalization of the dying in many countries. No study has attempted to analyse the changes in place of death in detail.

The aim was to analyse the 10-year trends in place of death of cancer patients, by region and by diagnosis, within England.

To do this, data on the place of death and patients' characteristics were derived from death registrations for all cancer deaths between the years 1985–94. We examined trends in the place of death for the whole of England, for each region separately and for the main cancer diagnoses.

The results show that there were over 1.3 million death registrations from cancer during the 10 years. The mean age increased over the period from 69.9 years in 1985, to 71.3 years in 1994. The percentage who died in a UK National Health Service (NHS) hospital or nursing home fell gradually from 58% (1985) to 47.3% (1994), while the percentage who died in non-NHS hospitals, nursing homes, hospices and communal establishments increased. The percentage who died at home fell slightly but steadily between 1985 and 1992 from 27% to 25.5% and since then increased slightly to 26.5% in 1994. The percentage of home deaths was lowest in the two Thames regions (less than 25%) and highest in the West Midlands, Anglia and Oxford (over 29%). These differentials were maintained across age groups and diagnoses. Older people and women were less likely to die at home than younger people and men. Significant trends showing an increase in home deaths were found in two regions: North Thames and South Thames. Patients with cancers of the lung, colorectum, respiratory organs, bone or connective tissue and lip, oral cavity and pharynx were more likely to die at home (over 29% in 1994) than patients with cancers of the breast (women, 25% in 1994) or the lymphatic or haematological system (16% in 1994).

It can be concluded that the trend towards a reducing home death rate from cancer in England appears to have halted, although this varies between regions. This has implications for primary care services. Although hospital is still the most common place of death from cancer, the percentage of cancer patients who die in hospital is reducing. The largest rise is in the increasing use of hospices and communal establishments, including residential and nursing homes. Given the ageing population, this trend is likely to continue.

Keywords

hospices palliative care home care services neoplasms primary health care mortality hospitals

Get full access to this article

View all access options for this article.

References

Portenoy R . Cancer pain: pathophysiology and syndromes. Lancet 1992; 339: 1026–1031.

Dunlop R , Davies RJ , Hockley JM . Preferred versus actual place of death: a hospital palliative care support team study. Palliat Med 1989;3: 197–201.

Townsend J , Frank AO , Fermont D et al. Terminal cancer care and patients' preference for place of death: a prospective study. Br Med J 1990; 301: 415–417.

Ashby M , Wakefield M . Attitudes to some aspects of death and dying, living wills and substituted health care decision-making in South Australia: public opinion survey for a parliamentary select committee. Palliat Med 1993; 7: 273–282.

Hinton J . Can home care maintain an acceptable quality of life for patients with terminal cancer and their relatives? Palliat Med 1994; 8: 183–196.

Cartwright A . Changes in life and care in the year before death 1969–1987. J Public Health Med 1991; 13: 81–87.

Mann WJ , Loesch M , Shurpin KM , Chalas E . Determinants of home versus hospital terminal care for patients with gynaecological cancer. Cancer 1993; 71: 2876–2879.

Bowling A . The hospitalisation of death: should more people die at home? J Med Ethics 1983; 9: 158–161.

Miller FG , Fins JJ . A proposal to restructure hospital care for dying patients. N Engl J Med 1996; 334: 1740–1742.

10.

Doyle D . Domiciliary terminal care: demands on statutory services. J Roy Coll Gen Pract 1982;32: 285–291.

11.

Higginson I , Webb D , Lessof L . Reducing hospital beds for patients with advanced cancer. Lancet 1994; 344: 409.

12.

Higginson IJ . Palliative care: a review of past trends and future directions. J Public Health Med 1993; 1: 3–8.

13.

Hospice Information Service . 1997 Directory of Hospice and Palliative Care Services. London: St Christopher's Hospice, Sydenham, 1997: x–xi.

14.

Costantini M , Camoirano E , Madeddu L et al. Palliative home care and place of death among cancer patients: a population based study. Palliat Med 1993; 7: 323–331.

15.

Mor V , Hiris J . Determinants of site of death among hospice cancer patients. J Health Soc Behav 1983; 24: 375–383.

16.

Addington-Hall J , McCarthy M . Dying from cancer: results of a national population-based investigation. Palliat Med 1995; 9: 295–305.

17.

Emanuel EJ , Fairclough DL , Daniels ER , Clarridge BR . Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805–1810

18.

Jarman B . Is London over-bedded? Br Med J 1993; 306: 979–982.

19.

Steadman K , Franks A . A woman with malignant bowel obstruction who did not want to die with tubes. Lancet 1996; 347: 944.

20.

Jarman B . Identification of underprivileged areas. Br Med J 1983; 286: 1705–1708.

21.

Balarajan R . Certification of death and the clinician. Health Trends 1982; 15: 53–56.

22.

Wenning GK , Quinn NP , Daniel SE . How accurate is death certification of multiple system atrophy? Lancet 1992; 340: 1481–1482.

23.

Death certification in asthma [Editorial]. Lancet 1984; 2: 676.

24.

Levi F , La Vecchia C , Lucchini F , Negri E . World–wide trends in cancer mortality in the elderly, 1955–1992. Eur J Cancer 1996; 32A: 652–672.

25.

Pollock AM , Vickers N . Why are a quarter of all cancer deaths in south-east England registered by death certificate only? Factors related to death certificate only registrations in the Thames Cancer Registry between 1987 and 1989. Br J Cancer 1995; 71: 637–641.

26.

Pollock AM , Benster R , Vickers N . Why did treatment rates for colorectal cancer in south east England fall between 1982 and 1988? The effect of case ascertainment and registration bias. J Public Health Med.1995; 17: 419–428.

27.

Thorpe G . Enabling more dying people to remain at home. Br Med J 1993; 307: 915–918.