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Journal of Clinical Oncology, Vol 23, No 10 (April 1), 2005: pp. 2441 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.322
Pattern of Care at the End of Life: Does Age Make a Difference?Division of Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada To the Editor: We read with interest the article by Gagnon et al1 reporting the results of a retrospective review of the care received during the last 6 months of life for 2,291 women dying of breast cancer in the province of Quebec, Canada, from 1992 to 1998. The authors reported a high proportion of hospital deaths (69.9%), and a low rate of home deaths (6.9%). They also found that specialists took care of 77.8% of these women in their last 6 months of life, and that more than half of the women who actually died at home were under the care of a general practitioner. The authors cite previous studies that have shown that most patients dying of cancer would prefer, if possible, to die at home.2,3 In the Gagnon et al study, the low rate of home deaths is correlated with a low rate of palliative care referral (9.7%) and a high rate of specialist care at the end of life. They also evaluated whether during the last hospital admission before death physicians shifted their care-oriented approach to comfort care and limited consultations to services other than palliative care. However, they found that the opposite was the norm. While some acute hospital admissions at the end of life are unavoidable, it seems from clinical experience that admissions usually occur as a result of poor coordination of palliative care services or primary caregiver distress. At the Toronto-Sunnybrook Regional Cancer Centre, coordination of palliative care and other supportive care services is facilitated by a dedicated social work team. In a recent audit of breast cancer deaths in our own practice (60 patients who died between 2001 and 2004), we found that while 71% of patients wished, if possible, to die at home, 33% actually died at home, and 26% died in a palliative care unit. More than 85% of these patients had been seen by social work services before death. Unlike the study by Gagnon et al, the rate of deaths in an acute care setting in our practice was 40%. In a survey of the health care professionals involved in the care of these patients, it was felt that an earlier referral to social work and earlier discussion of available palliative and supportive care services may have helped us to meet the desires of more patients and their families. In our experience social workers not only offer improved communication between family, patient, and staff, but also offer insight into the many different services required to allow for a patient, who so wishes, to die at home. Early referral to social work or other supportive care services may facilitate an increase in the palliative care approach through efficient utilization of scarce palliative care resources. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Gagnon B, et al: Pattern of care at the end of life: Does age make a difference in what happens to women with breast cancer? J Clin Oncol 22:3458-3465, 2004
2. Townsend J, et al: Terminal cancer care and patients' preference for place of death: A prospective study. BMJ 301:415-417, 1990
3. Hays JC, et al: Preference for place of death in a continuing care retirement community. Gerontologist 41:123-128, 2001
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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