Europe varies widely in at-home cancer deaths

NEW YORK Mon Mar 29, 2010 4:18pm EDT

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NEW YORK (Reuters Health) - European countries show wide variations in the percentage of terminally ill cancer patients who spend their last days at home, according to a study published online Monday.

Enabling terminally ill patients to die at home rather than a hospital is one of the goals of palliative, or end-of-life, care. And studies from various countries have found that the large majority of patients prefer to live out their last days at home.

However, the number who actually has that wish fulfilled may vary widely among Western European nations -- in a way similar to what's been seen in the United States.

Looking at cancer deaths in six European countries during 2002 and 2003, researchers found that the proportion taking place at home ranged from a high of 45 percent in the Netherlands to a low of 13 percent in Norway.

In England and Wales, those figures were 22 percent and 23 percent, respectively, while Italy had a rate of 36 percent and Belgium 28 percent, according to findings published in the Journal of Clinical Oncology, a cancer journal.

Dying at home is considered to be an aspect of a "good death," lead researcher Dr. Joachim Cohen, of Vrije University Brussel in Brussels, Belgium, told Reuters Health in an email.

Figuring out why there are nation-to-nation differences in at-home deaths may help improve those rates in places where few terminally ill people live out their last days at home, according to the researcher.

One important reason for the Netherlands' high rate, Cohen said, may be its "culture of open communication between patient and physician" -- which includes advance care planning for the end of life -- along with government policies that promote home health care.

"Whatever the explanation," he said, "we believe that the cross-national differences identified in our study need to incite certain countries to think about how they can learn from policies in other countries with considerably larger proportions of cancer patients dying at home."

The findings are based on death certificate data from England, Wales, the Netherlands, Norway and two Belgian cities for 2003, and from Milan, Italy, for 2002.

Certain factors were related to the likelihood of a cancer patient dying at home. Patients with solid tumors, for example, were more likely to die at home than those with hematologic, or blood-related, cancers.

One reason for that, Cohen said, may be that, with the intensive chemotherapy regimens used for blood cancers, patients were more likely than those with other cancers to die from treatment-related side effects while in the hospital.

"On the other hand," he added, "we also believe it to indicate that access to palliative care for hematologic cancer patients may be systematically lower, perhaps because hematologists are less eager to refer to palliative care and treat their patients much longer in hospital."

The researchers also found that in countries that had data on patients' education levels -- Belgium, Italy and Norway -- more-educated patients were more likely to die at home than those with lower education levels.

Cohen said this is a "striking" finding, particularly in countries where the healthcare systems are designed to give everyone equal access to care, including home healthcare services.

It's possible, he noted, that patients with lower education levels are less likely than their more-educated counterparts to express their wishes for end-of-life care, and may more often let their doctors make the decisions.

Educating all patients and their families about their choices on end-of-life care is essential, according to the researchers.

The differences among European countries in this study are similar to, or even larger than, those that have been seen among U.S. states, Cohen and his colleagues note. One U.S. study found that in 2001, the proportion of cancer deaths that occurred at home ranged from 25 percent in South Dakota to more than 60 percent in Utah.

That is despite the fact that several U.S. studies have found that between 80 percent and 90 percent of terminally ill patients say they want to die at home.

SOURCE: Journal of Clinical Oncology, online March 29, 2010.

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