HOME VERSUS HOSPITAL DEATH - ASSESSMENT OF PREFERENCES AND CLINICAL CHALLENGES

In Canada hospital beds have been reduced in number, and there is incr eased fiscal pressure for patients with advanced terminal illness to b e cared for in their own homes until death. In this issue (see pages 3 61 to 367) Drs. Ian R. McWhinney and Martin J. Bass and Ms. Vanessa Or r report that people who die at home rather than in hospital are more likely to be cared for by family members other than a spouse and to ha ve the services of a private duty nurse. The literature has shown that health problems of elderly spouses, occupational and other responsibi lities of family members, and the physical, psychologic and financial strain of providing home care can make it difficult to honour a termin ally ill person's wish to die at home. The findings of McWhinney and c olleagues point to the existence of a two-tiered health care system in which those who have access to private duty nursing are able to stay at home to die. Their study also raises three key questions that must be addressed in the assessment of patient preferences as to place of d eath: Should family members be included in the assessment? How should preferences be measured? and What is an appropriate time frame for suc h an assessment? Although McWhinney and colleagues identity characteri stics of care associated with place of death and underline the need fo r careful assessment of patient preferences regarding place of death, further research is needed to build on these findings. In the current context of health care reform, we need to examine more closely the typ e and intensity of services needed to support patients and their famil ies in the final stages of a terminal illness.