Significant values represented in bold type Only variables
Significant values represented in bold type.
Only variables significant on multivariate analysis at P < 0.05 are represented in this table, adjusting for cancer type.
unsure, which may indicate a lack of communication about end-of-life care, between the patient and the caregiver. Such communication would be complicated by the lack of acknowledgment of the terminal stage of the illness by the patient. Most of our patients did not acknowledge being terminally ill. Patients who considered themselves relatively well were less likely to die at home if preferred. A previous study from our center reported that most patients (76.9%) would not want to know how long they had to live even if their doctors knew.26 This finding highlights a further challenge to effective and appropriate communication about end-of-life preferences between health care providers, patients, and their CH 223191 and may also affect illness understanding. Inadequate communication and subsequent inappropriate expec-tations could add to the emotional and physical burden on caregivers trying to cope with limited re-sources and result in hospitalization of the patient. A lack of illness understanding and continued hope for cure may also have driven some patients, especially younger ones, to return to hospital for further treat-ment and ultimately to die there.
Enabling patients to die in their preferred place is considered an indicator of effective palliative care pro-vision.1 From our study, we observed that most pa-tients did not die in their preferred setting and that while most preferred to die at home, most were dying in hospital. Patients who received morphine for pain were more likely to die where they preferred, and pa-tients whose family caregivers knew that they wanted family present at the end of life were more likely to die at home.
Health care practitioners should be urged to discuss with terminally ill patients, their goals of care, and end-of-life preferences including preferred POD and should encourage such communication between
patients and their families as well as discussing prac-tical options for meeting their needs.1,27 However, given our patients’ responses to discussing dying with their doctors, more research is required to under-stand and implement best practice in facilitating culturally appropriate end-of-life communication.
Challenges to providing care at home by caregivers may contribute to terminally ill patients choosing to die in hospital or not dying at home if they preferred to. Adequate palliative care services provide support for patients and families, both practically and emotionally. Accessible palliative care may lead to more patients dying in their preferred place, espe-cially if at home. The association between morphine usage and achieving preferred POD in our setting may indicate better access to palliative care for those patients; however, this cannot be assumed and needs to be explored in more depth.
Our study has highlighted factors that are associated with terminally ill cancer patients treated at CHBAH, dying at home or in a preferred setting. Further research is required to improve our understanding of these associations to improve the services required to support patients and their families.
Disclosures and Acknowledgments
This work was supported by research grants from the National Cancer Institute awarded to Drs. Jacob-son, Joffe, Neugut, and Ruff (R01 CA192627); Dr. Ste-phen Emerson and Dr. Ruff (P30 CA013696-41S4) (subaward no. 1 [GG010416-62]; Dr. Abate-Shen and Charmaine Blanchard (P30 CA013696-43S4) (suba-ward no. 3 [GG010416-BI]; and Dr. Prigerson (R35 CA197730); as well as the South African Medical Research Council/University of the Witwatersrand. Common Epithelial Cancer Research Centre (MRC/ University of the Witwatersrand CECRC) awarded to Dr. Ruff and the Conquer Cancer Foundation Young Investigator Award to Dr. O’Neil.