"Other" includes other specified locality, other health-care facilities or private homes (excludes unknown localities)
Data source: Statistics Canada, Vital Statistics Death Database
"Other" includes other specified locality, other health-care facilities or private homes (excludes unknown localities)
Data source: Statistics Canada, Vital Statistics Death Database
Figure 5.3ii
Percentage of all cancer deaths occurring in hospital, private home or other, by province — 2011 death year
“Other” includes other specified locations, other health care facilities, private homes and unknown locations.
Hospices can be classified as “Other” or “Hospital” depending on province.
The definition of hospital varied across provinces. QC: “Hospital” included residential and long-term care centres. MB: Designated palliative care units were included in “Hospital.” In other provinces this type of bed might have been considered part of long-term care (“Other”). As a result, percentages of hospital deaths for QC and MB may appear higher relative to other provinces but do not necessarily indicate any actual differences in delivery of services.
The way palliative care beds are designated in hospitals varies across provinces. The resulting variation in reporting deaths that occurred in hospital is unknown.
Coding on death certificates varies by province. SK and PE: A very small proportion of deaths are recorded at home, suggesting that most in-home deaths may be recorded in “Other.”
Data source: Statistics Canada, Vital Statistics Death Database.
“Other” includes other specified locations, other health care facilities, private homes and unknown locations.
Hospices can be classified as “Other” or “Hospital” depending on province.
The definition of hospital varied across provinces. QC: “Hospital” included residential and long-term care centres. MB: Designated palliative care units were included in “Hospital.” In other provinces this type of bed might have been considered part of long-term care (“Other”). As a result, percentages of hospital deaths for QC and MB may appear higher relative to other provinces but do not necessarily indicate any actual differences in delivery of services.
The way palliative care beds are designated in hospitals varies across provinces. The resulting variation in reporting deaths that occurred in hospital is unknown.
Coding on death certificates varies by province. SK and PE: A very small proportion of deaths are recorded at home, suggesting that most in-home deaths may be recorded in “Other.”
Data source: Statistics Canada, Vital Statistics Death Database.
Cancer patients prefer to die at home, but the majority die in hospital from 2005-2009.
What are we measuring?
This indicator examines the percentage of cancer patients who die in hospital versus non-hospital locations based on the national vital statistics database.
Several Canadian surveys have suggested that the majority of cancer patients prefer to die at home if they are well supported or at a hospice in the presence of loved ones, if they have a choice. Hospitals, however, remain the most common – though least preferred – place of death.401
Statistics Canada data from 2003 to 2005 show more than 70% of cancer deaths occurred in hospital settings, emphasizing the disparity between end-of-life practice and patient preference. In its special topic on end-of-life care, the 2010 Canadian Cancer Statistics publication confirmed that measures are still needed to refine end-of-life care systems and to address the uneven access to end-of-life services both within and among provinces.401,402 A population-based survey conducted in the United Kingdom found that while 63% would prefer to die at home, only 27% felt that home would provide a pain-free experience during their final days, which was the main priority or concern identified for the final days.403
Several provinces have palliative and end-of-life care as a focus of their provincial health system strategy. National efforts are integrating palliative and end-of-life care into health systems through increasing support and access to information and enhancing clinical delivery.
An important limitation of this indicator is that it measures only location of patients at time of death; it does not take into account where they might have spent the majority of their days before death and how the health and emergency systems are used. It also does not account for hospices located in acute-care hospitals.
While a crude measure, the indicator presented in this section allows for the identification of potential opportunities in this segment of the cancer control continuum that could be further investigated through more detailed data collection and analysis. For instance, we do know that the process of death from cancer, possibly combined with confounding comorbid health factors, can affect the overall process of palliation that may be required. Cancer deaths will more often follow the terminal illness trajectory. We know quality of life can be sustained for many patients for months or even years, allowing for flagging, tracking, quality care and appropriate advance care planning to be incorporated before the end of life, wherever it may occur. Early identification of palliative needs and adoption of a simultaneous care model are needed to provide care that is person-centred and not driven by prognosis, if the outcome is to decrease undesired hospital deaths.
What are the results?
For almost all provinces, the majority of colorectal cancer deaths occur in hospital. Based on available vital statistics data from the 10 provinces, the percentage of colorectal cancer patients who die in hospitals ranged from 46.7% in Prince Edward Island to 84.5% in Manitoba (Figure 5.4ii).
Inconsistencies exist, however, in how provincial databases categorize the various locations of death, particularly the designation of hospital-based hospices.
For most provinces, the proportion of deaths in-hospital is similar for colorectal cancer patients compared to the proportion reported for all cancer patients (Figure 5.3ii).
What do the results mean?
There are many factors that might influence the proportion of cancer patients that die in hospital compared to other locations. These include patient factors, such as age, type of illness and availability of support, as well as health system factors, such as the way services are delivered and the availability of community services (e.g., hospice care).
Studies from several countries show that a large proportion of people who die from colorectal cancer die in the hospital468. A study from Ireland showed that 49% of colorectal cancer deaths occur in hospitals469.
A study examining health care use among men over 65 years old with colorectal cancer showed that use of hospice is increasing470. Availability and use of hospices may impact the percentage of people who die in the hospital versus other locations.
A collaborative effort, informed by the Quality End-of-Life Care Coalition of Canada’s Blueprint for Action 2010 to 2020, has led to advancements in palliative and end-of-life care across Canada and across different health-care environments. The federal government funded the Strategy on Palliative and End-of-Life Care, which aims to increase the number of hospitals and long-term care facilities that offer high-quality end-of-life care.418
The Canadian Partnership Against Cancer (the Partnership) has identified palliative and end-of-life care as one of its high-impact priorities for 2012 to 2017, which will help to advance and accelerate jurisdictional initiatives and support co-ordinated pan-Canadian planning in this important domain. Below is a list of areas that the Partnership will support to improve capacity to report on palliative care across the country:
There will be continued investments to support people in palliative and end-of-life care through the education and training of oncology professionals with the Education in Palliative and End-of-Life Care–Oncology Canada curriculum.
The Partnership collaborates on the Way Forward Project, which is dedicated to building a road map for an integrated palliative care approach and increasing the conversation that would incorporate patients’ and families expressed wishes about end-of-life care.
Canadian Virtual Hospice, an online resource with information on palliative and end-of-life care for patient caregivers and health professionals, will continue to expand its services to create knowledge tools that are clinically relevant, patient-centred and evidence-informed.
Enhancing the Quality of Palliative and End-of-Life Care for Children with Cancer is a collaborative project with The Hospital for Sick Children and the University of Toronto.
Cancer Care Ontario, with partners in Quebec, is piloting integrated palliative care models that encourage primary care providers and oncology teams to take ownership of basic palliative care with support from partnering palliative care specialists.
Emergency health services and palliative care are being integrated to enhance the end-of-life experience for Nova Scotia and Prince Edward Island cancer patients and their families.
Emerging evidence and studies
The ACCEPT initiative was a multi-year prospective study examining processes related to advance care planning for people with serious illnesses and their family members across 12 acute-care facilities in Canada.419 The study aimed to examine the extent to which critically ill patients were engaged in advance care planning, how well it was perceived and communicated and how it aided in their decisions for end-of-life care. Results showed that fewer than half of the participating patients reported having completed a written advance care plan. As well, barriers exist in the communication taking place between physicians and their patients. This may result in patients receiving unwanted treatment which is due largely to ineffective communication prior to hospitalization and/or to poor documentation of the patient’s preferences.
The Canadian Medical Association Journal recently released a “conversation guide” produced by the Canadian Researchers at the End-of-Life Network to help physicians walk through the steps of end-of-life discussions with patients, their families and caregivers.420 A pocket card, “Just Ask,” with important questions about advance care planning was produced for health-care professionals caring for people with serious illnesses.421
Definition: Percentage of deaths of cancer patients by location: hospital, other health care facility, private home, or other location
Numerator:
By province: Number of cancer deaths in: hospital; other
Canada: Number of cancer deaths in hospital; private home; other
Denominator: Number of cancer deaths
Data source: Canadian Vital Statistics – Death Database (annual file)
Measurement timeframe: 2005 to 2009
Stratification variables: Province
Notes:
All deaths in British Columbia in 2005 and 2006 were recorded as unknown location.
In the figure, Cancer patient place of death, by province – 2009, unknown location was excluded. “Other” included other specified locality, other health care facility and private home.
In the figure, Cancer patient place of death, Canada – 2005 to 2009, “Other” included other specified locality, other health care facility and unknown locality.
Includes data from all provinces and territories.
Data and measurement considerations
Data for this indicator were submitted by the provinces to Statistics Canada. The Canadian Vital Statistics Death Database includes a data element identifying cause of death and location of death grouped into the following categories: hospital, other health-care facility (e.g., long-term care or chronic-care facility), private home, other specified locality and unknown.
It is important to note that there are various discrepancies in the vital statistics data used to calculate these indicators, particularly around interpretation of the location categories described above. For example, a hospice can be categorized as an “other health-care facility” or as an “other specified locality,” but it could also be located in an acute-care hospital and therefore designated as a hospital setting. It is hoped that reporting on these results will provide an incentive to improve data quality and standardization so that appropriate comparisons can be made. Other regional and jurisdictional considerations include deaths in formal palliative care beds in hospitals, which are more accurately considered hospice deaths. Rural and remote residence may contribute to lack of access to home palliative care, and in some First Nations, Inuit and Métis communities there is no designated health-care funding for palliative care, resulting in the need for patients to stay in hospitals in urban centres.
Percentage of cancer patients admitted to an intensive care unit in the last 14 days of life and percentage dying in an ICU, by province/territories – 2011/12 to 2014/15 fiscal years combined
