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Stringer (23) notes that death is inevitable, and end-of-life issues should not be taken for granted. Dying enables individuals to put their lives into perspective and comprehend the real meaning of life. The author also notes that dying is a helpless time and if mishandled, it results in immense pain and fear. In this view, it is important that old people be afforded the most comfortable end-of-life environment. Bell, Somogyi-Zalud and Masaki (483-484) also note that ‘bad death’ has negative impact on the patient and the family and friends left behind. The quality of experiences in the last days and hours on earth remains in the memories of those left behind. Stringer (24) acknowledges that ‘bad death’ results in feelings of helplessness and anger among those left behind, as the experience is likely to be disturbing.
Cohen, Bilsen and Hooft (320) acknowledge the place of death as a major determinant of the quality of the dying process. The authors note that the perceptions towards death in developed nations have evolved over the decades. Initially, most patients preferred home based and compassionate deaths surrounded by friends and families. Currently, patients seem to prefer the medicalized and institutionalized options for their end-of-life care.
Moreover, the modern society seems to view death as the end of pain and suffering. Stringer (24) argues that dying at home promotes ‘good death’ as a patient is likely to experience love and support by his or her family members. Conversely, Cardenas-Turanzas, Torres-Vigil and Tovalın-Ahumada (881) argue that dying at home does not ultimately result in ‘good death’. The authors indicate that death in hospital ensures that terminally ill patients get the best medical care and proper management of pain. There are two objectives assessed in the current study. First, to determine whether home based death is better than hospital or institutionalized death. Second, to assess whether home based end-of-life care ultimately results in ‘good death’. In this regard, the research questions are:
- Is home based death better than hospital or institutionalized death?
- Does home based end-of-life care ultimately result in ‘good death’?
According to Cohen et al. (320-321), the place of death is an important issue in determining the quality of palliative care. Additionally, the debate on the best place to die attempts to establish the best environment that the patient will experience ‘good death’. Foreman, Hunt and Luke (448) acknowledge the superiority of home-based death as it promotes closure among those left behind and the dying process is made easier due to the love afforded by the family members.
However, Cohen et al. (321) note that home based death may not be the best option as purported by past research as the caregivers are likely to be stressed by the experiences of their loved ones. Stringer (25) argues that the notion of ‘good death’ is determined by the characteristics and the preference of the patients and their families. Although past research indicates that most elderly patients prefer home-based deaths, many end up dying in institutions (Bell, et al., 483).
In a research study undertaken by Cohen et al.( 321) to compare home and hospital based deaths, the findings revealed that that home based deaths do not ultimately lead to ‘good death’ for all the patients. The authors argued that home based death was dependent on the desire and physician demand for institutionalized therapy. The authors also noted that old cancer patients were more likely to experience ‘good death’ in institutions due to the ease of access to pain management therapies and quality medical care. Cohen et al. (322) also explained that older patients with severe respiratory infections that require particular therapies would experience better death in institutions. Therefore, home based deaths may not always be realistic and the differences between the wishes of the patients and practice are based on the nature of certain illnesses and their implications on the dying process.
Temkin-Greener and Mukamel (127) argue that hospital based deaths are undignified and pay little or no regard to the patient’s dignity. The authors note that such deaths make patients ‘public objects’ that are handled at the convenience of health professionals. Additionally, the demand of the health providers in institutional deaths seems to overshadow those of the patients. Specifically, patients tend to have little freedom in dictating the way they prefer to be treated. In support of this argument, Cardenas-Turanzas et al. (881-882) indicate that hospital-based death dehumanizes the dying process and causes social segregation of the patients. In this view, it is highly unlikely that the patients die in peace, as their minds are likely to be in distress during the dying process. Stringer (24-25) notes that good and bad deaths are likely to occur in both institutions and homes.
The author reports that the environment provided during the dying process in both institutions is the major determinant of the quality of the dying process. Similarly, an empirical review by Bell et al. (483), argues that the patient’s inclinations are likely to determine whether they experience good or bad death. The similarity between the favored and the actual place of death promotes the quality of the dying process. The empirical research also found out that most of the patients who preferred to die at home ended up dying in institutions. The authors explain that these trends are caused by changes in the national policies of different countries to discourage home based deaths.
Foreman et al. (448-449) undertook a prospective cohort study to determine the preferred place of death among South Australians. Findings from the research indicated that patients with malignant tumors and diseases with short duration of survival were most likely to die in hospitals. The research also discovered that patients with short survival illness were less likely to think about their preferred place of death compared to terminally ill patients.
Consequently, the cohort study reported that access and affordability of palliative services are also determinants of the place of death among old people. Kafetz (537) indicates that terminally ill patient’s preferences of home-based death are likely to change as the disease advances. Moreover, the misery about being a burden to the caregivers at home is likely to change their choice to institutional based death. The research by Foreman et al. (450) revealed that patients with illnesses that were more advanced preferred hospital based deaths expressing concerns regarding the quality of care at home. Stringer (26) acknowledges that respect for personal preference on the place of death promotes autonomy and the quality of end-of-life experience by a patient.
Cardenas-Turanzas et al. (883-884) report that the prevalence of home and institutional based dying varies across different nations, and it is dependent on the cost of medical care. The authors also note that rural populations in America, Spain, and Italy tend to prefer home to hospital based deaths. Such trends are due to their access of palliative care programs. Therefore, the health care systems of different nations play a role in determining the preferred place of death. The authors give an example of the healthcare system of the United States and state that the availability of hospital beds plays a major role in determining the place of death.
Moreover, this research found out that clinical and social features of the healthcare systems influences patient’s preferences on hospital based death. The study concluded that family support influences a patient’s decision on home based death. In a different research by Temkin-Greener and Mukamel (126-127), the findings indicated that 82 percent of extremely ill patients preferred to die at home due to the loving environment provided by their family members.
On the contrary, 43 percent of the chronically ill patients stated that they preferred to die in a nursing home, as they would get the best palliative care. These patients also cited the availability of trained health professionals to assist them in case of any emergencies. Stringer (26) acknowledges the difficulties in determining the best place to die as patients are likely to have their own preferences. Moreover, Cohen et al. (320) argue that family stability and support are likely to influence a patient’s decision regarding home based death. Patients whose families are unstable are more likely to prefer hospital-based death compared to those whose families are supportive. Temkin-Greener and Mukamel (133) argue that the preferences of the patients are more likely to matter in determining the place of death in comparison to the characteristics of the local healthcare systems.
Globally, developed nations are on a campaign to promote home based dying for the elderly (Fukui, Yoshiuchi and Fujita). Despite such efforts, the United States and United Kingdom continue to report more hospital based deaths. In addition, there has been an increase in the number of palliative care professionals and facilities. International guidelines for end-of-life care recommend that patients be given the freedom to decide on the place of death.
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In this respect, Fukui et al. (885-886) undertook a population-based survey to determine people’s choices on the place of death. Based on their findings, the quality of hospital based care and individual’s characteristics determined whether the participants preferred home or hospital based death. Specifically, older female patients preferred to die at home, as their families would give them more personalized care. These patients also indicated that having their loved ones close would make the dying process easier. The same research revealed that old female patients without daughter in laws preferred hospital based dying. This is an indication of the importance of support systems in home based dying. Generally, 42.9 percent of the participants favored home-based death, 49.1 percent preferred institutional-based death while the rest had no preference.
In a different research by Temkin-Greener and Mukamel (127-128), the authors assessed patients perceptions on the PACE program, a community based care facility for the elderly and terminally ill patients. The research revealed that most of the participants (45 percent) desired to die at home. The findings also showed that patients with ‘do not resuscitate’ directive were 7.4 times more likely to die at home. This research recognizes the importance of acknowledging the characteristics of the patients in determining the quality of the dying process. Furthermore, patients who have their own directives on how they what to die have higher probability of dying at home as their wishes are more likely to be respected in comparison to hospital based dying.
Houttekier, Cohen and Bilsen (133-134) claim that quality end-of-life care can only be achieved if the wish of the dying patient is respected. However, the authors note that deaths caused by accidents may not ensure that such wishes are honored. Relatives of terminally ill patients are more likely to prefer home based death as it would ensure that they spend more time with their loved one. Hospital-based care may limit the amount of time that the patients spend with their families due to the limited visitation. Moreover, some families may not afford the high cost of medical care associated with hospital-based end-of-life care.
High medical costs may limit the uptake of hospital services by old terminally ill patients as the dying process may take months or even years. Stringer (25) also notes that the availability of palliative care professionals who make home visits promotes the quality of home based end-of-life care. In the research undertaken by Houttekier et al. (132), the authors compared the place of death between participants living in urban and rural regions in Belgium, The Netherlands, and England. Based on their analysis, the authors reported that participants living in urban areas were more likely to die at home. The authors concluded that the limited availability of hospital beds in urban regions restricted the utilization of institutionalized end-of-life care. Cohen et al. (322) outline three reasons that could promote the utilization of hospital based end-of-life care.
First, patients with high levels of education are likely to utilize home based end-of-life care and hire professionals to take care of them at home. Second, patients who prefer higher and more advanced medical care are more likely to select hospital based end-of-life care. Lastly, the cultural differences between the patients and health professionals are likely to influence the choice of the patients. In specific, limitations in communications between patients and their physicians may cause the patients to choose home based end-of life care. In reference to Cohen et al. (320), individuals living alone and without other family members are more likely to utilize hospital-based care. Stringer (26) notes that the differences in the cost of home and hospital based end-of-life care varies from nation to nation. In this view, such differences are likely to affect the uptake of end-of-life care based on the social classes of the patients.
Kafetz (537-538) supports the uptake of hospital based end-of-life care, as the elderly are able to retain control over their lives until they die. The author notes that the dying process among the elderly results in unavoidable destructions of the self. Thus, there is the need for them to be surrounded by round-the-clock medical professional and counseling services. Elderly terminally ill patients present with apathy and withdrawal symptoms due to their poor physical functions.
Stringer (26-27) notes that the family members may not be well prepared to deal with the changes in personality associated with the dying process. Thus, hospital based end-of-life is the best option for elderly terminally ill patients. Kafetz (537) also notes that terminally ill patients chose euthanasia due to the desire to die with dignity and eliminate the emotional and financial burden that their illnesses elicit on their families.
However, the author notes that such death with dignity may not always be achieved by both hospital and home based end-of life care. Therefore, it is unlikely that home based care would result in a more dignified death in comparison to hospital-based care. Houttekier, Cohen and Bilsen (134) acknowledge that terminal illnesses like cancer are characterized by other symptoms such as hallucinations, immobility, and lack of control of urinary and fecal motions. Such complications warrant hospital-based care for better management. Moreover, proper management of these symptoms is likely to promote the quality of the dying process.
Kafetz (537) notes that hospital based care is the best choice for the elderly due to the uncertainty of the courses that their illnesses are likely to take. Furthermore, hospital based end-of-life care enhances the interactions between the patients and their physicians and hence better disease prognosis. In summary, many researches have in the past compared hospital and home based dying and death. This research reveals that choosing either hospital or home based end-of-life care does not automatically result in good or bad death. Researchers in support of home based dying argue that patients are likely to be at peace due to the presence of their loved one. Additionally, proponents of hospital based dying argue that the terminal illnesses are managed better. Despite such views, it is clear that one must consider the personal characteristics of the patients and the features of the healthcare system when assessing the best end-of-life care.
Death is an inevitable part of life and hence the best quality care should be given to the dying (Stringer 23). The dying process is characterized by helplessness and distress. Thus, the provision of good environments during end-of-life care is likely to promote the quality of the dying process (Cohen, et al., 320). Based on this research, home-based care is not always better than hospital-based care. This is because terminal illnesses managed better in the presence of medical professionals.
Moreover, taking care of an elderly terminally ill patient may cause distress among the family members. According to Cohen et al. (321), patients whose families are unstable and unsupportive are likely to fair well in hospital-based end-of-life care. Past research also proves that the patients’ personal characteristics and preferences also determine the best place to die. Honoring the patient’s wishes ensures that they die with dignity.
Moreover, patients with orders such as ‘Do-not-resuscitate’ are more likely to choose to die at home. In reference to the second objective, home based dying does not automatically result in ‘good death’. The personal characteristics, disease progression, and the love given by the family members determine whether the patients experience good death. Therefore, the current research disapproves the notion that home is ultimately the best place for old people to die. The major limitation of the current research is the lack of evidence-based investigations as the findings are based solely on past research studies. Thus, more comprehensive epidemiological research designs are required to assess the aforementioned research questions.
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