When asked, many people say they want to die at home, in the comfort of a familiar place with loved ones. More than half of very elderly and seriously ill patients express their desire to die at home (Lynn et al., 1997), but a disturbing study revealed that the number of hospital beds, not patient and family preference, was the most influential factor in determining the site of death (Pritchard et al., 1998). Although some people with cancer will die "suddenly," most are more likely to experience a decline (hours, days, weeks) before their deaths (IOM, 1997). This period of decline may lead to hospital transfer for evaluation or for care that is becoming too intensive to be rendered by the primary caregiver. Some people may experience a decline in health while already in the hospital.
Patients, families, and physicians may fail to plan for these declines, thereby ensuring that a trip from home to hospital will occur for lack of other means to maintain safety and comfort. Health care systems often lack clear, easily implemented procedures to enable transfer of patients from hospital to home with necessary services when death appears imminent or inevitable. Patients, families, and health care professionals may not recognize or believe that death is approaching, so treatments are continued without discussion of the impending death and where it should take place.
Cancer deaths in hospital should be reduced, and monitoring should be performed to verify that transfers are appropriate. Charts should be reviewed of all transfers occurring within 24 hours of death. Compliance with patient and family preferences, patient status, readiness of destination (hospital bed or oxygen in the home, for example), and plan for continuity of care should be documented and monitored to reduce the likelihood of inappropriate transfer.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].