Can We Choose Where We Die?
The Reality of Fulfilling Our Final Wish
If we could choose exactly where to spend our final moments, would we actually be able to make it happen? For many, this desire—to pass away in a specific place—is the last and most significant wish of their lives. But is it realistically achievable?
Drawing from my experience in Palliative Care within the Department of Family Medicine at Ramathibodi Hospital, I have found that there is often a significant gap between where patients want to die and where they actually die.
The Gap Between Wish and Reality
Many patients express a strong desire to pass away at home. A study from Taiwan indicates that approximately 67% of terminally ill patients wish to die at home (1). However, in practice, several barriers often prevent this:
Medical Necessity: Doctors may need to monitor unstable symptoms in a hospital setting.
Home Unreadiness: The home may lack necessary medical equipment, sufficient medication, or a sterile environment.
Caregiver Anxiety: Families often feel unprepared or fearful about nursing a dying relative at home, preferring the safety of a hospital until the very end.
The "Bed Clearing" Dilemma Conversely, there are cases where terminally ill patients no longer require intensive medical treatment, but they are not ready to return home. While hospitals may need to discharge these patients to "free up beds" for new cases, families are often paralyzed by fear and lack of preparation, creating a difficult conflict.
The Importance of "Place of Death" in Palliative Care
In countries like Australia (2) and the UK (3), facilitating death in the patient's preferred location is a core mission of Palliative Care. It is recognized as a factor that directly impacts the patient's quality of life in their remaining time, as well as the emotional well-being of their family (3).
Despite efforts to support these wishes, success rates vary wildly. Research shows that 30% to 91% (4) of patients globally die in their preferred location. A systematic review supports the finding that patients often do not die where they wish, with a statistically significant risk of mismatch (weighted risk ratio of 1.23) (5).
Key Factors for Success (4):
Strong support from the medical team.
Commitment and readiness of the family.
Access to Hospice Care or specialized end-of-life facilities.
Do Wishes Change as the End Approaches?
It is crucial to note that a "preferred place of death" is not static. An Australian study found that while most people initially say they want to die at home, this preference often shifts to Hospices or Hospitals as death approaches and symptoms worsen (2).
The Reality of Home Death vs. Facility Death:
Only 37.5% of those who wanted to die at home actually achieved it.
In contrast, 62.5% to 76.9% of those who chose a care facility (Hospice, Nursing Home, or Hospital) passed away in their preferred location.
Global Trends: The Decline of Home Deaths
Globally, statistics show a shift away from dying at home toward dying in healthcare institutions.
UK: Home deaths have dropped from 31% to 18% over the last 30 years, with predictions suggesting it could fall to 10% in the future (6).
Belgium: About 73% of deaths occur in hospitals or care facilities, while only 24% occur at home. Those who die in institutions are more likely to be non-cancer chronic patients, have lower education levels, or live alone (7).
The Challenge in Thailand
Making this "final wish" come true is particularly challenging in the Thai context.
The "Cure" Focus: Thai hospitals are designed primarily for curing—using advanced technology to treat disease. This often conflicts with the Palliative goal of caring (minimizing suffering).
Lack of Facilities: Hospice Care (specialized facilities for the dying) is a concept that is just beginning to gain attention in Thailand and is not yet widely established.
Conclusion
The patient's desire regarding their place of death is something medical professionals must prioritize. Alongside driving serious policies for Palliative Care, we must expand care services to cover both homes and specialized care facilities. Only then can we ensure true quality of life for patients until their final breath.
Source: https://www.rama.mahidol.ac.th/fammed/th/article/postgrad/writer18/place_of_death
