Monday, 17 July 2017

Dying in the hospital: some considerations

Gloria Gálvez

Health inequalities are related to individual and social factors. The way people live, work and grow old as well as the political, social or economic factors that accompany them, vary greatly according to the place where they live. Death, which could be "the great equalizer", doesn’t appear to be equal at all, as Dr. Puri states in his article "Unequal Lives, Unequal Deaths," in which she argues that social and health differences during life, are also present at the time of death. As a group of Danish authors suggest in BMJ Supportive & Palliative Care: "Socioeconomic position and place of death of cancer patients” for people with fewer resources it’s more difficult to benefit from a worthy death in their own home.

When a patient chooses to die in a health institution he does it for different reasons. Higginson et al., In "Dying at home - is it better: A narrative appraisal of the state of the science" identified, besides the socioeconomic level, other determinant elements as the preferences of the patients, the access to the home attendance or the support of the family. Let's look at each one separately.

Patient preferences and the role of caregivers. Lessening the family burden can be decisive when choosing the place where one wishes to die. In the study by Agar, Currow, Shelby-James et al. published in Palliative Medicine, it was possible to associate patients' preference for dying in hospitals with the feeling that they had towards becoming a family burden. In this sense, the caregivers’ role is of great relevance, since death at home, even if it’s calmer and less painful, requires a wider caregiver support. This is highlighted in the article published in BioMed Central: "Dying at home leads to more peace and less grief, but requires wider support", and in different studies that point to a strong relation between place of death and family support, to the point that the availability of a caregiver in the family is the predictor of greater possibility for the patient to decide to die at home.

Disease Progression 

As the disease progresses, it becomes more difficult to manage pain and control symptoms. At this time, patients and caregivers may consider that in the hospital the patient would benefit from better treatments than at home. In this sense, the article published in Plus One: How Could Hospitalisations at the End of Life Have Been Avoided? A Qualitative Retrospective Study of the Perspectives of General Practitioners, Nurses and Family Carersen sets out 5 key elements that could help avoid hospitalization at the end of life:

1) The change of mentality when death approaches;
2) Being able to provide treatment and care at home in times of crisis;
3) Interventions to cope with expected complications;
4) Guiding the patient and his family in a global way against the disease;
5) Continuity of care and treatment in the home.

The availability of home care services such as home hospitalization, palliative care and other social and health resources are some of the most important factors associated with the place of death. Thus, the geographical context in which people live will condition access to this type of resources, being a factor to be taken into account when analyzing the place where the patient dies.

Several studies highlight the importance of information on the place where the patient dies as a reflection of social and territorial inequalities, which should promote decisions based on the evidence on health policies according to the different territories and degrees of accessibility to appropriate services. In addition, they provide us with interesting information about patient and caregiver while allowing us to review the stereotype of patients with little responsibility in their self-care. The reality is more complex, so the health team must facilitate decisions taken in a fair and equitable environment. Recognizing this reality must allow alternative places to be cared for at the end of their lives and provide them with the most comfortable and dignified options for everyone, not only for those who enjoy socio-economic stability.

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