No one likes to talk about terminal illness, but the stigma surrounding this subject is being punctured a bit by a growing realization: In the U.S. these sorts of tragic situations are exacerbated by a lack of planning beforehand, unnecessary medical procedures and associated discomfort, and — less important — a great deal of expense that does little or nothing to improve outcomes. We “do” death worse than a lot of other wealthy countries.
How can we improve this? One answer has to do with where people who are dying spend their final hours and days. There’s a growing pile of evidence suggesting it’s better to die at home, where you’re more likely to be surrounded by friends and family and be relatively comfortable, and less likely to be subjected to pointless invasive medical interventions.
This is an area where there haven’t been a great deal of large, careful studies, though, which is why a Japanese one just published in the journal Cancer is so important. (There isn’t yet a link up, but I’ll add one once it is.)
A large team of Japanese researchers led by Jun Hamano of the University of Tsukuba examined the records of 2,069 patients who died of cancer — 1,607 in the hospital and 462 at home. They were curious whether this would make a difference for survival time, measured from when they were first referred to the hospital in question for treatment. “To the best of our knowledge,” the authors write, “this is the first large-scale, prospective, multicenter study” asking this question. And it’s an important question to ask: If patients who spend their final days in a hospital live longer, after all, it would complicate the argument that dying at home is a preferable outcome: Different patients and families might have different opinions on whether an extra, say, ten days is “worth” a little more pain, potentially invasive procedures to extend life, and so on.
What the researchers found, though, was that patients who died at home actually lived longer, or at least as long, as patients who died in the hospital. This has important ramifications for medical decision-makers in terms of how they frame the options available to patients and their families: The finding “suggests that an oncologist should not hesitate to refer patients for home-based palliative care simply because less medical treatment may be provided.”
Importantly, the authors highlight two factors that could account for the fact that staying in a hospital didn’t increase survival time: Those who died in the hospital were given significantly more parenteral hydration (IV drips to keep them hydrated) and antibiotics. Neither treatment seemed to impact survival time, which tells a familiar story of hospitals doing procedures that might seem effective but that don’t actually extend patient life.
This was a study that took place only in Japan, so it could be the case that things work differently in the U.S. or elsewhere. Still, we have a trend on our hands here: Most of the evidence on end-of-life care seems to be pointing in the same direction, which is that deaths in nonhospital settings, when feasible, offer better outcomes. Not that this is an easy thing to discuss.