Awareness of General Practitioners concerning cancer patients’ preferences for place of death: Evidence from four European countries

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Abstract

Background

General Practitioners (GPs) are at the first level of contact in many European healthcare systems and they supposedly have a role in supporting cancer patients in achieving their desired place of death. A four-country (Belgium, the Netherlands, Italy and Spain) study was carried out exploring current practices.

Patients and Methods

EURO SENTI-MELC adopted a retrospective study design and data for this study were collected in 2010 through representative GPs’ networks in four countries. In the current study all non-sudden cancer deaths were included with weekly GP registrations.

Results

The main study sample included 930 deceased cancer patients: preference for place of death was known by GPs for only 377. GP awareness on the preferred place of death varied across countries, 27% in Italy, 36% in Spain, 45% in Belgium and 72% in the Netherlands (p < 0.01). The general level of preferences met was high, from 68% (Italy) to 92% (Spain).

Conclusions

Despite the importance of being able to die in a preferred location, GPs were often unaware about patient preferences, especially in Italy and Spain. If GPs were informed, the preference was often met in all countries, indicating room for improvement in end-of-life care.

Introduction

Cancer is a leading cause of death in Europe with standardised statistics demonstrating more than 169 deaths per 100,000 inhabitants annually died from malignancies.1 Therefore, offering quality cancer care is crucial and palliative care is one element. Achieving patients’ preference is a marker in assessing quality of care1 and place of death deserves attention because it gives patients and their families a sense of control and thus improving the quality of death.2 Meeting patients’ preferences of place of death enhances the quality of cancer care in addition to other goals such as symptom control and spending time with family at the end-of-life.3

Existing literature shows that from 44% to 90% of individuals (both cancer patients and healthy population) worldwide desire to die at home4, 5, 6, 7 while these wishes often remain unfulfilled. Hospital deaths account for 35% to 65% cancer deaths in the United Kingdom (UK) and 45% in the Netherlands.8, 9, 10 Information on how well this preference is met (congruence between actual and preferred place of death) is less known. One Italian survey reports an overall 67% of sampled patients died in their preferred place of death11 whereas the proportion drops to just over 50% in an Irish study.12 A recent study shows an increase of home deaths in Britain, from 18% in 2004 to 21% in 2010, the rise is more pronounced among cancer patients.13 This might be related to the introduction of the End-of-Life Care Strategy in 2008,14 which includes place of death as a quality indicator, demonstrating the potential benefits of integrating palliative care into public health.15

This study uses General Practitioners (GPs) as proxies for information. Though precise statistics on GPs’ coverage are not available, previous studies highlight their role in improving palliative care services.10, 16, 17 Abarshi shows that four-fifths of patients had their preference met when Dutch GPs knew them10 while Meeussen et al. show that only 46% of Belgian GPs knew the preferred place of death of their cancer patients,17 indicating room for improvements.

An international study on preference met with regard to GPs’ involvement in end-of-life care for cancer patients would add to the knowledge on improving GP-patient communications.

The study aims of this article are:

  • (1)

    To report GPs’ awareness of preferred place of death of a sample of deceased cancer patients in four European countries (Belgium, the Netherlands, Italy and Spain).

  • (2)

    To estimate the distribution of actual and preferred place of death from a sample of deceased cancer patients in the four countries.

  • (3)

    To describe preference met in the sampled cancer patients.

Section snippets

The EURO SENTI-MELC study

The European Sentinel Network of the GPs to Monitor End-of-Life Care (EURO SENTI-MELC) is a large scale epidemiological descriptive study conducted in four European countries in 2009–2010 based on continuous full-year registration of all patients who died in the participating GP sentinel networks. The study started in Belgium in 2004 and expanded to the Netherlands in 2005 and has continued since then.

Observational unit

General practices are the observational units. The GP network covers 1.8% and 0.8% of the

Selection of sample (Fig. 1)

A total of 3336 deaths were reported from the four countries with 938 ‘non-sudden’ cancer deaths. Preference met on place of death was analysed for 377 patients whose ‘preferred’ and ‘actual’ place of death were known.

Patient characteristics

There was no difference between cancer patients in terms of age but more male patients were included. (Table 1). One fourth of patients aged between 18 and 64 (except in Italy), 60% of patients aged between 65 and 85; the very old (aged 85 or above) comprised another 15%. Forty

Discussions

This is the first cross-European study to measure preference met on place of death for cancer patients from a general practice population. For actual place of death, home deaths varied from one-third in Belgium to over 60% in the Netherlands. 70–90% of GPs reported home as the preferred location of their cancer patients. The proportion of preference met was high (over 80%), except in Italy. Both results are supported by the existing literature.6, 10, 11, 17

One finding is the large cross-country

Strengths and limitations

This is a European-wide study on preference met on place of death among cancer patients, using GPs as proxies. The same methodology was applied in four countries, allowing comparisons across territories. The choice of countries, Belgium, the Netherlands, Italy and Spain reflects the diversity of healthcare systems and cultures. Furthermore, efforts have been made to achieve the best representativeness possible and GPs reported weekly to minimise recall bias.

Nevertheless there are limitations

Conclusions

It has been repeatedly reported that patients wish to die at home.4, 5, 6, 7 The article describes the current situation and explores conditions related to the preferred place of death in four European countries. Except in the Netherlands, the majority of GPs surveyed were not aware of the preferred place of death of patients and where this was the case, patients usually died in hospitals. Nonetheless, by offering training to GPs on end-of-life care communication, better arrangements can be

Funding

EURO IMPACT, European Intersectorial and Multidisciplinary Palliative Care Research Training, is funded by the European Union Seventh Framework Programme (FP7/2007–2013, under Grant agreement N° [264697]). EURO IMPACT aims to develop a multidisciplinary, multi-professional and inter-sectorial educational and research training framework for palliative care research in Europe. EURO IMPACT is coordinated by Prof Luc Deliens and Prof Lieve Van den Block of the End-of-Life Care Research Group, Ghent

Conflict of interest statement

None declared.

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