Place of Death: Different by Design
Comment on “Association of Hospice Patients' Income and Care Level With Place of Death”

Modern hospices deliver specialized care for dying patients in several settings where patients are cared for and die. The specialization of care is useful given that patients in general have complex needs, and their care requires a high level of education, staff, and other resources. Evidence suggests that specialist palliative care significantly improves pain and other symptom control for these patients and their family members. However, were hospices designed to meet the needs of all persons facing death? For a start, not all patients with specialized palliative care needs are eligible for hospice care.¹ For instance, patients with hospice referrals must meet certain criteria, one of which is to have a shortened life expectancy (sometimes ≤90 days). This criterion means the typical hospice patient is at best one whose illness trajectory is predictable and perhaps unidirectional.² Although we ideally wish to extend hospice use to all patients, proponents of this idea need to remember that the cancer trajectory is well suited for a hospice selection. Hospices are not always able to meet the needs of patients with very severe symptoms.³ They are not uniformly distributed in all regions and often have different styles of operation. Not all patients can afford hospice care. More important, hospices seldom appeal to every culture, religion, and generation. Barclay and colleagues⁴ have demonstrated in their article that the hospice simply cannot provide care for everyone. That said, patients with limited resources tend to have limited knowledge about the benefits of a specialized facility such as a hospice. They are less likely to die in a hospice, for a number of reasons, even if the services provided were free. Furthermore, these patients perhaps are less likely to enroll in a home-based program, because some have not embraced the culture of dying at home and thus would not choose a home death, irrespective of the content or the quality of the care package offered. In addition, age-related inequalities may account for variations in preferences.