Study in JCO finds dying at home is better for cancer patients

September 15, 2010

As reported in a recent study in the Journal of Clinical Oncology, cancer patients who die at home do so more peacefully, and their caregivers end up doing better emotionally, too.

As reported in a recent study in the Journal of Clinical Oncology, cancer patients who die at home do so more peacefully, and their caregivers end up doing better emotionally, too.

At-home hospice care not only saves money but saves physical and emotional pain as well, they reported in the Journal of Clinical Oncology.

“Patients with cancer who died in an intensive care unit or hospital experienced more physical and emotional distress and worse quality of life at the end of life,” Alexi Wright, MD,  of the Dana-Farber Cancer Institute in Boston and colleagues wrote.

“If patients are aware that more-aggressive care may affect not only their quality of life, but also their loved ones after their death, they may make different choices,” Wright said in a statement.
Wright's team studied 342 terminal cancer patients and their loved ones until the patients died, usually about 4 1/2 months later.

“Although most patients with cancer prefer to die at home, 36% die in a hospital and 8% die in an intensive care unit (ICU).

When patients died in an ICU, their loved ones were five times more likely to be diagnosed with post-traumatic stress disorder, or PTSD, Wright's team found
Twenty-one percent of caregivers of patients who died in an ICU developed PTSD, compared with 4.4 percent of those caring for patients who died with home hospice.

"This is the first study to show that caregivers of patients who die in ICUs are at a heightened risk for developing PTSD," they wrote.

Families and loved ones of patients who died in the hospital were also more likely to have prolonged grief disorder, an intense, disabling form of grief that lasts more than six months.
Home-based hospice care is meant to relieve suffering, but at least one study last month showed it may also help cancer patients live a little longer.

It also costs far less than treating cancer patients in a hospital. “Nearly 25% of Medicare expenditures are spent on intensive care in the final month of life, despite limited evidence of improved patient outcomes,” Wright’s team noted.

The study:

Place of Death: Correlations With Quality of Life of Patients With Cancer and Predictors of Bereaved Caregivers' Mental Health

Purpose To determine whether the place of death for patients with cancer is associated with patients' quality of life (QoL) at the end of life (EOL) and psychiatric disorders in bereaved caregivers.

Patients and Methods Prospective, longitudinal, multisite study of patients with advanced cancer and their caregivers (n = 342 dyads). Patients were followed from enrollment to death, a median of 4.5 months later. Patients' QoL at the EOL was assessed by caregiver report within 2 weeks of death. Bereaved caregivers' mental health was assessed at baseline and 6 months after loss with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the Prolonged Grief Disorder interview.

Results In adjusted analyses, patients with cancer who died in an intensive care unit (ICU) or hospital experienced more physical and emotional distress and worse QoL at the EOL (all P ≤ .03), compared with patients who died at home with hospice. ICU deaths were associated with a heightened risk for posttraumatic stress disorder, compared with home hospice deaths (21.1% [four of 19] v 4.4% [six of 137]; adjusted odds ratio [AOR], 5.00; 95% CI, 1.26 to 19.91; P = .02), after adjustment for caregivers' preexisting psychiatric illnesses. Similarly, hospital deaths were associated with a heightened risk for prolonged grief disorder (21.6% [eight of 37] v 5.2% [four of 77], AOR, 8.83; 95% CI, 1.51 to 51.77; P = .02), compared with home hospice deaths.

Conclusion Patients with cancer who die in a hospital or ICU have worse QoL compared with those who die at home, and their bereaved caregivers are at increased risk for developing psychiatric illness. Interventions aimed at decreasing terminal hospitalizations or increasing hospice utilization may enhance patients' QoL at the EOL and minimize bereavement-related distress.