Dying at home leads to more peace and less grief, but requires wider support

Dying at home could be beneficial for terminally ill cancer patients and their relatives, according to research published in the open access journal BMC Medicine.

09 oct 2015--The study shows that, according to questionnaires completed by their relatives, those who die at home experience more peace and a similar amount of pain compared to those who die in hospital, and their relatives also experience less grief. However, this requires discussion of preferences, access to a comprehensive home care package and facilitation of family caregiving.
Previous studies have shown that most people would prefer to die at home. In the UK, US and Canada, slightly more appear to be realising this wish, while in Japan, Germany, Greece and Portugal, a trend towards institutionalised dying persists.
Despite differing trends, the most frequent location of death for cancer patients remains hospital. Evidence regarding whether dying at home is better or worse than in hospital has, however, been inconsistent.
The new study took place in four health districts in London covering 1.3 million residents. 352 bereaved relatives of cancer patients completed questionnaires after their death - 177 patients died in hospital and 175 died at home. The questionnaires included validated measures of the patient's pain and peace in the last week of life and the relative's own grief intensity.
Lead author Barbara Gomes from the Cicely Saunders Institute at King's College London, UK, said: "This is the most comprehensive population-based study to date of factors and outcomes associated with dying at home compared to hospital. We know that many patients fear being at home believing they place an awful burden on their family. However, we found that grief was actually less intense for relatives of people who died at home.
"Many people with cancer justifiably fear pain. So it is encouraging that we observed patients dying at home did not experience greater pain than those in hospitals where access to pain relieving drugs may be more plentiful. They were also reported to have experienced a more peaceful death than those dying in hospital."
The study found that over 91% of home deaths could be explained by four factors: patient's preference; relative's preference; receipt of home palliative care in the last three months of life and receipt of district/community nursing in the last their months of life. When Marie Curie nurses (which provide additional home support) were involved, the patient rarely died in hospital. The number of general practitioner home visits also increases the odds of dying at home.
Three additional factors were also identified that had been previously overlooked - length of family's awareness of that the condition could not be cured, discussion of patient's preference with family, and the days taken off work by relatives in the three months before death. The authors say this challenges current thinking about the influence of patient's functional status, social conditions, and living arrangements, which showed no association once other factors are considered.
Barbara Gomes said: "Our findings prompt policymakers and clinicians to improve access to comprehensive home care packages including specialist palliative care services and 24/7 community nursing. This is important because, in some regions, the workforce providing essential elements of this care package is being reduced."
The researchers also highlight the crucial role of families in caring for patients at home and in decision-making processes, and the need to facilitate family caregiving.
Barbara Gomes added: "Many relatives see dedicated care as something they would naturally do for their loved one, but it still represents out-of-pocket money or days off their annual leave. Some governments, for example, in Canada, the Netherlands, Norway and Sweden, have set up social programmes or employment insurance benefits, similar to maternity leave, aimed at supporting families to provide care for their dying relatives.
"We urge consideration of similar schemes where they do not exist, with the necessary caution associated with complex public health interventions - careful development, piloting and testing, prior to implementation."
Limitations of the study include its retrospective and observational nature, showing associations which do not necessarily indicate causality. The transferability of findings to regions outside of London, where home care services are less available, is uncertain. Subjective factors, pain and peace are also vulnerable to recall and observer bias from respondents.

More information: Barbara Gomes et al. Is dying in hospital better than home in incurable cancer and what factors influence this? A population-based study, BMC Medicine (2015). DOI: 10.1186/s12916-015-0466-5

Provided by BioMed Central

Cancer deaths to hit 17 million in 2030: researcher

By Michael KahnMon Sep 24, 1:17 PM ET
Cancer deaths will more than double to 17 million people each year in 2030 with poor countries shouldering the heaviest burden from the disease, the head of the United Nation's cancer agency said on Monday.
An ageing population will bump up cancer rates worldwide in the coming years, especially in developing countries where the number of people who smoke and drink is on the rise, said Peter Boyle, director of the International Agency for Research on Cancer.
And the disease will hit poorer countries harder because of limited health budgets and a lack of treatments such as radiotherapy that can extend people's lives, he told the European Cancer Conference.
"If we put population growth and ageing to one side the exportation of cancer risk factors, primarily tobacco smoking, from developed countries will continue to be a major determinant of cancer risk and cancer burden in less developed countries," he said.
For many years, many thought cancer was mainly a problem in rich nations in part because health officials assumed people in poorer countries did not live long enough to develop cancer.
This trend is changing, however, as residents of these nations live longer and continue cancer-causing activities like smoking that are declining in Western countries, Boyle said.
This will fuel a dramatic increase in worldwide cancer with the disease likely killing 17 million people each year by 2030, up from the current 7 million. The number of people diagnosed and living with cancer will treble to 75 million, he said.
"The big issue is ageing," he said. "The speed of the ageing of the population is something which is dramatically increasing, especially in the low and medium resource countries."
But he said Europe offers an example that something can be done because even as cancer cases rise, the disease is killing fewer people these days than expected.
This shows that programs such as increased screening and education aimed at preventing tobacco use helped whittle EU cancer deaths to 935,219 in 2000, nearly 10 percent below expectations.
"This approach has clearly paid off," he said. "In Europe good quality care exists for the great majority of people."
This is not the case in many poor countries, however, he said, noting that at least 30 African and Asian countries do not have radiotherapy machines.
Because of these kinds of deficiencies, more people will needlessly die from a rise in cancer and other chronic diseases that will stretch national health systems to the limit, he said.
He urged organizations and governments to focus more on a disease that kills more people each year than tuberculosis, malaria and AIDS combined.

More Education Equals Lower Cancer Death Risk

ATLANTA, Sept. 11 -- Having more than a high school education is associated with a lower risk of dying from cancer, researchers here said.
In a database study, men with 12 years of education or less died of cancer at more than twice the rate of those with more years of schooling, according to Jessica Albano, Ph.D., of the American Cancer Society.
There was a similar but lower association for women, Dr. Albano and colleagues reported online in the Journal of the National Cancer Institute.
Race and socioeconomic status are well known to influence mortality in the U.S., but few studies have looked at how they affect cancer mortality, the researchers said.
To fill that gap, they analyzed death certificates and census data for 2001 in 47 states and the District of Columbia, finding 137,708 cancer deaths among 119,376,196 individuals ages 25 through 64.
The lower age limit was chosen to ensure that those in the study had completed their education. The upper limit was chosen because data on educational attainment is more complete for those younger than 65, the researchers said.
To capture the variation in education, Dr. Albano and colleagues considered six levels -- zero through eight years of school, nine through 11 years, 12 years, 13 through 15 years, 16 years, and 17 years or more.
But for a broad picture, they compared those with 12 years of education or less to those with more. In that analysis, for all cancers combined, death rates per 100,000 were:
214.4 for black men with 12 years of education or less compared with 90.1 for those with more schooling. The relative risk was 2.38, with a 95% confidence interval from 2.33 to 2.43.
163.8 for non-Hispanic white men with 12 years of education or less compared with 73.0. The relative risk was 2.24, with a 95% confidence interval from 2.23 to 2.26.
148.1 for black women with 12 years of education or less compared with 103.3. The relative risk was 1.43, with a 95% confidence interval from 1.41 to 1.46.
128.8 for non-Hispanic white women with 12 years of education or less compared with 73 for those with more schooling. The relative risk was 1.76, with a 95% confidence interval from 1.75 to 1.78.
For each educational level, the researchers found, blacks also tended to do worse than whites.
For example, the death rate per 100,000 people among black women with more than 12 years of schooling was 103.3, while it was 73 among white women with the same educational level. (The relative risk was 1.42, with a 95% confidence interval from 1.39 to 1.44.)
The analysis turned up some novel findings, Dr. Albano and colleagues said.
For instance, black men with 12 years of education or less had a prostate cancer death rate of 10.5 per 100,000, compared with 4.8 for those with more schooling. A similar pattern but with a smaller difference was seen for white men, the researchers found.
The relatively large difference between the educational groups "suggests that modifiable factors associated with lower levels of education may play an important role" in prostate cancer mortality, especially among black men, they said.
A second novel finding was that -- in contrast to earlier studies -- breast cancer mortality rates were higher among women with less education than among women with more education.
Specifically, the rates for black women were 37.0 per 100,000 for those with less schooling and 31.1 for those with more, respectively, and for white women the rates were 25.2 and 18.6 per 100,000, respectively, Dr. Albano and colleagues said.
A range of possible risk factors might account for the differences, the researchers said, including access to health insurance, smoking habits, body mass index, and recent screening for breast or colorectal cancer.
The study "adds to the wealth of descriptive data on racial disparities in cancer mortality in the United States," according to Sholom Wacholder, Ph.D., of the National Cancer Institute.
But it's unrealistic to conclude that educational attainment in some way contributes to the disparities between blacks and white, Dr. Wacholder said in an accompanying editorial.
It's challenging, he said, to try to estimate the effect of race on educational achievement and equally difficult to estimate what effect increasing a person's educational level has on his or her later risk of death from cancer.
On the other hand, the data might be employed to suggest groups that might usefully be targeted for public health campaigns, he said. Knowing about unequal mortality rates can "provide hints about where a successful public health intervention might have the greatest potential impact," he said.
The study was supported by the American Cancer Society, which had no role in analysis or interpretation of the data. All authors but two are employees of the society. Additional source: Journal of the National Cancer InstituteSource reference: Albano JD et al. "Cancer Mortality in the United States by Education Level and Race." J Natl Cancer Inst 2007; 99: 1384-94. Additional source: Journal of the National Cancer Institute Source reference: Wacholder S. "Untangling Differences in Cancer Mortality Rates: A Closer Look at Race and Education." J Natl Cancer Inst 2007; 99: 1356-57.

UN, WHO must lead to lower cancer deaths: expert

By Daniel TrottaTue Apr 3, 5:59 PM ET
World bodies like the United Nations and World Health Organization need to develop a coordinated strategy to confront the rising cancer risk in poor countries, an international expert said on Tuesday.
The incidence of cancer, once considered a disease of the developed world, has increased in poorer countries and global policymakers are not keeping pace with the challenge, said Peter Boyle, director of the International Agency for Research on Cancer.
When the agency was founded in 1965, cancer was considered a disease that afflicted wealthy nations. That changed with the growth and aging of the population in poorer countries, which also imported more risk factors such as tobacco and alcohol abuse, obesity and the lack of physical activity, Boyle said.
Boyle's agency, part of the World Health Organization, estimates cancer cases will double from 2000 to 2030, with a majority of cases occurring in low- to medium-resource countries.
"The cancer control community worldwide has suffered from being very diverse, loose and uncoordinated, and it certainly could do with a lot of leadership and an overall coordinated strategy," Boyle told a news conference at United Nations.