Jane McCredie: A good death

I WALKED past an open doorway in the southern Italian village of Paestum some years ago.

It was early evening and, inside the room opening directly onto the street, a body lay on a table surrounded by flickering candles. Grieving relatives sat either side; neighbours came in and out, paying their respects.

It was a strangely beautiful scene — and a far cry from the way most of us in Australia experience death and grieving.

A century ago, people expected to die at home, surrounded by family and the material objects that had framed their lives.

These days, most Australians die in hospital, often spending the last days of their lives surrounded by various high-tech devices and subjected to possibly painful and often futile interventions.

It may seem surprising, but we actually don’t know a lot about exactly where Australians die, as Bureau of Statistics mortality data does not cover place of death.

The Australian Institute of Health and Welfare cites figures showing 52% of deaths in 2008‒2009 were in admitted patients, a figure that had remained more or less stable over the previous decade.

But others, such as Sydney intensivist Professor Ken Hillman, have put the rate much higher.

“Up to 70 per cent of people now die in acute hospitals; surrounded by well-meaning strangers, inflicting all that medicine has to offer; often resulting in a painful, distressing and degrading end to their life”, he writes in his book, Vital signs: stories from intensive care.

Although increasing recognition of the importance of palliative care has led to an easier path for many patients and their families, dying at home remains relatively rare.

Palliative Care Australia says only 16% of Australians die at home, despite it being most people’s preferred option.

The picture is quite different in the US, where moves to remove death and dying from the hospital setting have steadily gained momentum over recent decades.

In the early 1980s, Americans died in much the same way we do now — more than half of them in hospital and only 15% at home — according to medical historian Professor David J Rothman writing in the New England Journal of Medicine last week.

But that situation has changed. Professor Rothman cites a large cohort study suggesting more than a third of elderly Americans may now die at home, while fewer than 25% die in acute care hospitals.

Centers for Disease Control and Prevention figures from 2007 put the proportion of the overall US population dying at home slightly lower at 25%, but similarly chart a substantial increase over the previous two decades.

Part of the reason for the higher rate of home deaths in the US may be the extensive free services for those receiving palliative care at home (provided they are eligible for that country’s Medicare insurance scheme, that is).

Palliative Care Australia has been critical of private health insurers for their unwillingness to cover such services here.

The medical advances of the last century mean many of us will continue to die in hospital — and for good reason. Where a hospital admission offers a reasonable prospect of a good outcome, few of us would choose to turn our back on that, for all the accompanying risk that we might die in an institutional setting.

For those where a good outcome is less likely, though, the equation may be a very different one.

From either a financial or a compassionate point of view, it’s hard to understand why we would fail to support people who wish to die in familiar surroundings, and in the care of the people they love.

Jane McCredie is a Sydney-based science and medicine writer.