Best Place to die: Home or ICU?  ​

Dr Jay Patil

 

I read with interest Dr Bewley’s blog1- it’s a subject that I have thought about a lot. Invariably, on every ICU shift, myself or the ICU registrar gets the quintessential bleep that begin with “ we think this patient is not suitable for escalation to level 3 care but would be suitable for level 2 care…”, “ this patient is very young (30 to 60 years old) but with metastatic cancer and in multi-organ failure. Can you please provide organ support…”, and so on. This is usually about a patient who essentially is terminally ill but has been brought into hospital by well-meaning relatives, paramedics, or friends for further care- in other words “to die”. I have watched many a time, the paramedics having spent many heroic minutes trying to resuscitate patients in the community, bring them to A&E- sometimes with ROSC- only to watch with frustration, for us hospital doctors to pronounce that the patient is not suitable for escalation of care and to be palliated. 

Is hospital the right place to die- surely not? Dr Bewley’s patient had a “good death” due to many factors including the availability of an ICU bed (!!!) and the willingness of the ICU consultant to offer that precious bed to allow a dignified “good death”. The National Survey of Bereaved People (VOICES)2, administered by the Office of National Statistics, gathers information of people’s views on care provided to a relative or friend in the last 3 months of life. Though hospital care was rated as outstanding (69%), it was significantly lower than care homes (82%), hospice care (79%) or care at home (79%). Only 3% of respondents stated that patients wanted to die in hospital. Speaking for myself, I would like to be with my close family and friends at the time of my death- not in an alien environment, surrounded by strangers in varying stages of sickness and getting pricked and prodded till the day of my death. This view, I am sure is also shared by many of my colleagues, including palliative care physicians (personal communication).
Dr Bewley is also right to point out that the “good death” would have been a “better death” if the patient had died at home. So, surely, this discussion needs to happen in the community that includes the patient, family, GP and healthcare professionals involved in the patient’s care- not in the hospital at the time when the patient is mentally incapacitated due to various reasons. These timely decisions thereby not only involve the patient, but also caregivers who know most if not all aspects of the patient’s health and wishes. This is in direct contrast to myself, who has to make that call in 5-10 minutes, based on information provided over the telephone at 04:00 hrs. Though, we as healthcare professionals get this right most of the times, 20% of the surveyed respondents said that decisions were made about the patients’ care, which the patients themselves would not have wanted.

The survey also revealed that despite patients’ wishes, 74% of the respondents also felt that the hospital was the right place for the patient to die. This could likely be due to lack of appropriate support in the form of resources and trained personnel as well as information/ support to people who may have never seen death up close and personal. The survey also noted that when patients spent some or all of the last 3 months at home, the coordination between community services was significantly better for people who died at home than compared to any other site. This shows that once the patient leaves home to either the hospital, hospice or care home, this lack of coordination results in a worse outcome for the patient.

In this modern world, people are living longer with more debilitating diseases than in the past but death is inevitable. Both the general public as well as the healthcare professionals should acknowledge this fact and enable every human being a “peaceful death”.

 References: 
1. Bewley, J. A Good Death- On the ICU. Intensive Care Society. 28/11/2018. [Available at https://www.ics.ac.uk/ICS/Blogs/Blogs2018/AGoodDeath.aspx]. [Accessed 4th February 2019] 2. Office for National Statistics. National Survey of Bereaved People (VOICES): England, 2015. Quality of care delivered in the last 3 months of life for adults who died in England. Newport: ONS, 2016