Reply to D.C. Currow et al: Hospital Can Be the Actively Chosen Place for Death

Blogger's Note:  what has not been discussed is the patient's medical condition which may alter their decision/s

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Reply to D.C. Currow et al

Currow et al¹ are correct that a death at home is not necessarily a marker of high-quality care. On the contrary, many patients choose to spend their final days in other settings. Family concerns, the presence of young children in the home, the absence of adequate caregiving resources, and fears about symptoms may all influence the choices that patients make. Indeed, it was for this reason that we did not rely on a patient's site of death as the main outcome.

Instead, we used patients' preferences by asking, “Where would you prefer to live out the rest of your life?”^2(p2784) We acknowledge that there is always the potential that questions could be interpreted in a variety of ways. However, in this case, we are confident that our wording makes it clear to patients that the question refers to their future care, not to their present situation. We also note that it would be interesting to examine determinants of whether preferences were met for death in other settings (eg, in the hospital). This was outside the scope of the current study but is a focus of ongoing work.

Of course, preferences can and do change. It would be surprising, in fact, if preferences at the time of hospice enrollment remained constant throughout the course of care. Therefore, further research is needed to better understand whether and how these preferences change, and whether there are patient-level factors that predict a shift in preferences over time.

More generally, Currow et al¹ raise intriguing questions about the degree to which patients' preferences should influence their site of death. We agree that a patient's actual care is the product not only of a patient's preferences, but also of family preferences and circumstances. One might argue, in fact, that as caregivers, families should have a voice in determining where a patient should live out the final days of his or her life. Particularly when a death at home would result in substantial burdens or disruption, such preferences deserve consideration. However, it is also important to note that although palliative care providers must consider the family as a unit, it is the patient who is the focus of care. Therefore, although other preferences are important, we believe that it is important to ensure that patients' goals and preferences are assessed and documented. Nevertheless, further research is needed to determine how patient versus family preferences influence care, and how the preferences of multiple stakeholders in complex family situations should influence care.

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AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

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REFERENCES

1. 1.↵
   1. Currow DC,
   2. Agar M,
   3. Abernethy AP

   (2013) Hospital can be the actively chosen place for death. J Clin Oncol 31:651–652.

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2. 2.↵
   1. Jeurkar N,
   2. Farrington S,
   3. Craig TR,
   4. et al.

   (2012) Which hospice patients with cancer are able to die in the setting of their choice? Results of a retrospective cohort study. J Clin Oncol 30:2783–2787.

   Abstract/FREE Full Text