Patterns of death among patients treated at a Department of Medical

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ORIGINALES
Patterns of death among patients treated at a
Department of Medical Oncology in Spain
Jorge Aparicio Urtasun, Roberto Díaz Beveridge, Pedro López Tendero, Lorena Pellín Ariño,
Ángel Guerrero Zotano, Laura Palomar Abad, Jorge Molina Saera, Ángel Segura Huerta and
Joaquín Montalar Salcedo
Servicio de Oncología Médica. Hospital Universitario La Fe. Valencia. Spain.
Introduction. Despite significant advances in the
palliative care of cancer patients with terminal disease, a considerable proportion of them still die at
hospital. The causes of this fact are multiple including sociocultural, familial, and sanitary reasons.
Material and methods. A retrospective study was
performed on the place and cause of death among
patients treated at a Department of Medical Oncology in two time periods (10/ 1996-10/ 1997 and 2001)
in order to assess the actual situation and its evolution through the last years. Our department assumes both the active treatment and the palliative care of patients assigned to its area. In 2001, 1,254 new
cases were referred and 1,006 hospital admissions
were recorded, with a median stay of 11 days. In the
same period, 424 patients died.
Results. Of them, 250 (59%) deaths occurred at hospital (25% of the department discharges). The most
common neoplasms were lung (24%), colorectal
(14%), and breast (9%). The median hospital stay
was 8 days (range, 1-60). The causes of death were
cancer progression (79%), intercurrent diseases
(11%), and complications during active treatment
(10%). In comparison with the former group,
among patients dying at home there was a greater
relative percentage of women, diagnoses of breast
cancer, lymphoma and multiple neoplasms, elderly
patients, and deaths due to tumor progression.
Conclusions. Nearly 60% of cancer patients who die
in our environment do it at hospital. Of them, 20%
do not die specifically of tumor progression. The
pattern of deaths at home is somewhat different.
Sanitary resources should be adapted to the particular care features of each department, favoring the
development and coordination of palliative care
units, both hospital-based and home care teams.
Correspondence: J. Aparicio Urtasun
Servicio de Oncología Médica.
Hospital Universitario La FE.
Avda. Campanar, 21.
46009 Valencia.
E-mail: japariciou@ seom.org
Received 15 April 2004; Revised 8 July 2004; Accepted 22 July 2004.
39
Key words: advanced cancer, place of death, hospital,
home.
Aparicio Urtasun J, Díaz Beveridge R, López Tendero P, Pellín Ariño L, Guerrero Zotano A, Palomar Abad L, Molina
Saera J, Segura Huerta A, Montalar Salcedo J. Patterns of death among patients treated at a Department of Medical Oncology in Spain. Rev Oncol 2004;6(8):483-7
Patrón de fallecimientos entre los
pacientes atendidos en un Servicio de
Oncología Médica en España
Introducción. A pesar de los avances producidos en
los cuidados paliativos de los pacientes oncológicos
en fase terminal, un porcentaje significativo de éstos todavía fallece en el hospital. Las causas de ello
son múltiples: socioculturales, familiares y sanitarias.
Material y métodos. Realizamos un estudio retrospectivo de los lugares y causas de muerte entre los
enfermos atendidos en un servicio de Oncología
Médica en dos períodos temporales (10/ 199610/ 1997 y 2001) con el objetivo de conocer la situación actual y su evolución en los últimos años.
Nuestro servicio asume tanto el tratamiento activo
como los cuidados paliativos de los pacientes de su
área. En el año 2001 se atendieron 1.254 casos nuevos y se generaron 1.006 ingresos hospitalarios, con
una estancia media de 11 días. En este período se
produjeron 424 fallecimientos.
Resultados. De ellos, 250 (59%) ocurrieron en el
hospital (25% de las altas). Las neoplasias más comunes fueron pulmón (24%), colorrectal (14%) y
mama (9%). La estancia media fue de 8 días (rango,
1-60). Las causas de muerte fueron progresión tumoral (79%), enfermedades intercurrentes (11%) y
complicaciones durante el tratamiento activo (10%).
En comparación con los anteriores, entre los pacientes que fallecieron en su domicilio había un
mayor porcentaje relativo de mujeres, diagnósticos
de cáncer de mama, linfoma y neoplasias múltiples,
pacientes ancianos y muertes por progresión.
Conclusiones. Cerca del 60% de pacientes oncológicos que fallece en nuestro medio lo hace en el hospital. De ellos, un 20% no muere específicamente
Rev Oncol 2004;6(8):483-7
483
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APARICIO URTASUN J, DÍAZ BEVERIDGE R, LÓPEZ TENDERO P, ET AL. PATTERNS OF DEATH AMONG PATIENTS TREATED AT A
DEPARTMENT OF MEDICAL ONCOLOGY IN SPAIN
por progresión neoplásica. El patrón de fallecimientos en el domicilio es algo diferente. Los recursos sanitarios deberían adaptarse a las peculiaridades asistenciales de cada servicio, potenciándose el
desarrollo y coordinación de las unidades de cuidados paliativos tanto hospitalarias como domiciliarias.
Palabras clave: cáncer avanzado, lugar de fallecimiento, hospital, domicilio.
INTRODUCTION
Cancer represents one of the main causes of death in
the Western world, accounting for 20% of the overall
mortality. In fact, only approximately 50% of patients
with this diagnosis will become long-term survivors
of their malignant disease 1. Moreover, a significant
number of cancer patients die of causes different
from the neoplasm itself, such as intercurrent infections, concomitant diseases, and treatment-related toxicity.
Depending on the sociocultural context, especially in
North Europe, North America and Australia, a trend
has been noted to move the place of death towards
the familial environment and the patient’s home,
with the support of palliative home care teams2,3. In
contrast, many patient families in Spain still consider
dying at hospital as a sign of quality of care. The
practice of palliative care in cancer patients with terminal disease is differently distributed, as a function
of territorial resources, among departments of Medical Oncology, Palliative Care Units, hospices, and palliative home care teams4.
In order to investigate the actual situation and its evolution through the last years, a retrospective study
was performed on the causes of death among patients
treated at a Department of Medical Oncology in
Spain. Two one-year periods were analysed with a time interval of 5 years. The objective was to know the
prevalence of the underlying neoplasms, the main
causes of death, and the place and context of these
deaths in order to adequate the sanitary resources accordingly.
PATIENTS AND M ETHODS
Two one-year periods were retrospectively analysed:
period 1 (between October 1996 and October 1997),
and period 2 (between January and December 2001).
In both of them, all deaths occurred among cancer
patients admitted at the Department of Medical Oncology were recorded. Deaths occurring either at hospices or at other general hospitals were scant and so
excluded from this analysis. The following parameters were coded in the data base: patient age and gender, underlying neoplasm, situation at hospital ad-
484
mission (no prior diagnosis of malignancy, diseasefree or complete remission, active disease with specific treatment, or active disease with supportive therapy), cause of admission (initial study, complication
secondary to treatment, symptom control, or terminal
status), duration of hospitalisation before death, and
final cause of death (tumor progression, treatmentrelated toxicity, intercurrent disease, other causes).
Results were grouped and compared between the two
time periods analysed. Furthermore, in the second
period, a comparison was made between patients
dying at hospital and patients dying at home during
the same time. For patients dying at home, circumstances and causes of death were directly collected by
the investigators from family caregivers or palliative
home care personnel. Comparisons between groups
were performed by means of the Chi-squared test or
the Fisher exact test, when appropriate, and statistical
significance was defined as p<0.05.
Our department assumes both the active medical treatment and the palliative care of the majority of patients of its geographical area. There is no a specific
Palliative Care Unit, but we collaborate with a specialised home care team, and two hospitals for chronic
patients (hospices). Although there are no Medical
Oncology duties, our medical staff is available for
consulting about cancer patients’ admissions in the
Emergency Room every morning form Monday to
Friday, and approximately for 40% of the days in the
rest of time.
RESULTS
In 2001, 1,254 new cases of cancer were referred to
our department. A total of 1,006 hospital admissions
were generated, with a median hospital stay of 11
days. In the same time period, 424 patient deaths occurred, of which 250 (59%) took place at hospital,
thus representing 25% of our hospital discharges. Table 1 shows the comparison of the features of these
patients (period 2) with that of 193 patients who died
during hospital admission at our department in period 1 (with 1,000 new cases registered). This 29% increase in the number of deaths is related to the 25%
increase in the number of new cases per year achieved in this interval. The spectrum of diseases shows a
(statistically non significant) trend to an increase in
the percentage of deaths secondary to colorectal, breast, and esophagogastric cancers, whereas the relative percentage of deaths from lung cancer, head and
neck tumors, and lymphoma have decreased. This
could reflect their different prevalence, patient referral, prognosis, and pattern of place of death. In period 1, more patients were admitted in terminal status, whereas in period 2 there were more admissions
for staging studies (initial diagnosis or at relapse) or
due to treatment complications. These differences did
Rev Oncol 2004;6(8):483-7
40
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APARICIO URTASUN J, DÍAZ BEVERIDGE R, LÓPEZ TENDERO P, ET AL. PATTERNS OF DEATH AMONG PATIENTS TREATED AT A
DEPARTMENT OF MEDICAL ONCOLOGY IN SPAIN
TABLE 1. Comparison of characteristics among patients
dying at hospital in the two periods analysed
Number
Age (years)
Median
Range
Gender
Male
Female
Cancer type (percent)
Lung
Colorectal
Breast
Head and neck
Esophago-gastric
Lymphoma
Unknown primary
Bladder
Sarcoma
Multiple primary site
Other tumors
Cause of admission
Symptom control
Terminal status
Study (initial, relapse)
Treatment complications
Other, unknown
Cause of death
Tumor progression
Intercurrent causes
Died in 2001
Died between
10/96-10/97
250
193
64
24-48
57
18-83
159 (64%)
91 (36%)
116 (60%)
77 (40%)
24%
14%
9%
6%
8%
3%
5%
4%
3%
1%
23%
32%
8%
6%
11%
5%
8%
4%
3%
5%
2%
16%
42%
21%
18%
13%
6%
45%
29%
11%
10%
5%
79%
11%
81%
8%
not reach statistical significance. The other features
(age, gender, cause of death, and median stay) did not
differ among the periods of study.
Table 2 depicts the comparison of characteristics
among patients dying in 2001, either at hospital (250
cases) or at home (174 cases). In the former group,
the percentage of patients dying because of treatment-related toxicity was greater (p=0.002), whereas
in the latter patients tended to be more frequently older than 70 years (p=0.09) and women (p=0.049). Table 3 shows the relative percentage of patients dying
at hospital as a function of the tumor type. Patients
with neoplasms of the esophagus, bladder or stomach
were more likely to die at hospital. In contrast, patients with lymphoma, multiple neoplasms, and cancers of the breast, pancreas, cervix and central nervous system tended to die more frequently at home.
Comparisons between these groups of neoplasms were statistically significant.
For patients dying during hospitalisation in period 2,
further data were available that were not recorded for
period 1. Twenty-two percent of them died in the first
48 hours after admission. Although the terminal situation was formally addressed in the medical records for the majority of patients ("terminally ill patient" or "do not resuscitate" orders), only in 30% of
41
TABLE 2. Comparison of characteristics between patients
dying at hospital and patients dying at home (period 2001)
Number (percent)
Age (years)
Median
Range
> 70
Gender
Male
Female
Cancer type (percent)
Lung
Colorectal
Breast
Head and neck
Esophago-gastric
Lymphoma
Unknown primary
Bladder
Sarcoma
Multiple primary site
Other tumors
Cause of death
Tumor progression
Intercurrent causes
Treatment-related toxicity
Died at hospital
Died at home
250 (59%)
174 (41%)
64
24-84
65 (26%)
64
21-92
59 (34%)
159 (64%)
91 (36%)
94 (54%)
80 (46%)
24%
14%
9%
6%
8%
3%
5%
4%
3%
1%
23%
18%
11%
13%
5%
4%
7%
6%
2%
2%
4%
28%
79%
11%
10%
88%
10%
2%
TABLE 3. Number (percentage) of dying patients according
to the place of death by cancer type (period 2001)
Cancer type
Lung
Colorectal
Breast
Head and neck
Stomach
Esophagus
Lymphoma
Bladder
Unknown primary
Ovary
Multiple primary sites
Pancreas
Cervix
Central nervous system
Sarcoma
Prostate
Multiple myeloma
Place of death (mean)
Hospital
Home
250 (59%)
174 (41%)
60
36
22
15
13
07
08
11
13
09
03
04
05
03
07
06
05
(66%)
(65%)
(50%)
(65%)
(68%)
(87%)
(40%)
(73%)
(54%)
(64%)
(30%)
(50%)
(45%)
(27%)
(64%)
(67%)
(56%)
31
19
22
08
06
01
12
04
11
05
07
04
06
08
04
03
04
(34%)
(35%)
(50%)
(35%)
(32%)
(13%)
(60%)
(27%)
(46%)
(36%)
(70%)
(50%)
(55%)
(73%)
(36%)
(33%)
(44%)
them an express mention of specific pharmacological
treatment of this condition was evident. Finally, only
19% of patients dying of potential treatment-related
toxicity were admitted in the Intensive Care Unit.
DISCUSSION
For many centuries, most human beings have died in
the place they lived. However, in the 20th century, so-
Rev Oncol 2004;6(8):483-7
485
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APARICIO URTASUN J, DÍAZ BEVERIDGE R, LÓPEZ TENDERO P, ET AL. PATTERNS OF DEATH AMONG PATIENTS TREATED AT A
DEPARTMENT OF MEDICAL ONCOLOGY IN SPAIN
ciocultural changes in perception of the concepts of
life and death and significant advances in the practice
of medicine have moved the place of death from home to hospitals. Patient death is now more often seen
as a medical failure than as a natural outcome. In
fact, nearly 60% of terminal patients had active treatment in progress at the time of death in one study,
thus reflecting the treatment imperative to prolong life in western societies5. The percentage of cancer patients dying at the acute care hospital setting (in contrast with those dying at home) varies significantly
from 40% to 70% as a function of the period of study,
the geographical area, and the sanitary resources2-7.
Our data are in concordance with previous studies.
Nearly 60% of our cancer patients who die do it at
hospital. Their median hospital stay is short, reflecting a high percentage of admissions in terminal status. Some 20% of patients die from intercurrent causes or treatment-related complications, although
admission to the Intensive Care Unit is infrequently
asked. Main limitations and potential biases of the
present study are its retrospective nature and the fact
that it is a hospital-based population, thus making
difficult to generalize its conclusions. With a median
of 21 deaths per month, personal and sanitary resources should be adapted accordingly. However,
further collaboration with non hospital palliative care
units is evidently needed.
Approximately two-thirds of cancer patients, when
asked about the preferred place of death, wish to die
in their own homes. During the last decade it is becoming increasingly more common for dying patients
to be offered home care by their relatives with the
support of an advanced palliative home care team 8.
In fact, a recent trend has been noted to rise the proportion of people who die out of the hospital9.
A number of individual patient factors are known to
be predictive of the place of death among terminal
cancer patients7, 9-16: female gender, children, elderly
people, residency in rural areas, longer survival after
diagnosis of cancer, functionally dependent patient
status, family support (more than one caregiver), patient’s and caregiver’s desires, support of their family
physician, and availability of advanced palliative home care are associated with an increased frequency
of death at home, whereas haematological malignancies, short survival after diagnosis of cancer, black
ethnicity, low income, low social class, low educational level, residency in deprived areas, family exhaustion, rehospitalisation, and prolonged home nursing
care are predictors of dying at hospital. For elderly
patients, factors predicting death in the general hospital for men were digestive comorbidities, vomiting,
and weakness, whereas for women were functional
dependency and lack of social support17.
Although some results are conflicting among studies,
the type of primary tumor seems to be related with
486
the chance of dying at hospital16. The present study
confirms previous data regarding the influence of
gender and age in the place of death, but also shows
how certain cancer types (breast, lymphoma, multiple primary site) are more commonly associated with
death at home whereas others (esophagus, bladder,
stomach) frequently predict for death at hospital. This
trend could be related to other described factors such
as the length of survival and specific tumor complications (bleeding, digestive tract obstruction, etc.).
We have not specifically addressed other features
such as family support, income, educational level,
and social class. However, it is becoming evident that
if advanced palliative home care is easily available,
adequately offered, and caregivers instructed, an increasing percentage of terminally ill cancer patients
would benefit of dying at home, thus increasing the
congruence between patient’s preferred and actual
place of death18.
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APARICIO URTASUN J, DÍAZ BEVERIDGE R, LÓPEZ TENDERO P, ET AL. PATTERNS OF DEATH AMONG PATIENTS TREATED AT A
DEPARTMENT OF MEDICAL ONCOLOGY IN SPAIN
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