Which patients with terminal cancer are admitted from home care?

The factors related to admission of patients with terminal cancer who had been referred to a reputable home care service were examined in 415 patients referred in a two-year period and in a prospective study of a randomized one in three sample of the 232 adults still alive one week after referral, who were able to converse and be at home with caring relatives. The reasons given by staff for intermediate admissions were mostly to improve symptom control or provide respite; for final admissions the reasons were symptom control, patients' deteriorated state and relatives needing relief. Independent weekly assessments usually concurred in showing increasing problems or distress preceding final admission, particularly patients' weakness, pain, depression and anxiety, and relatives' fatigue, anxiety or depression. Examination of selected demographic and illness factors indicated that few patients living alone or with unfit relatives stayed at home; breast cancer led to more deaths as an inpatient, whereas stomach cancer favoured deaths at home. The proportion of patients admitted steadily increased as care lengthened. Assessments of psychological factors showed that initial attitudes of denial, conscious fighting of disease, and optimism were linked with increased late admissions; earlier awareness of dying in patients and stoicism in relatives favoured home deaths. A growing preference for inpatient care usually preceded or accompanied admission. Recognition of both immediate and underlying causes of admission can indicate where further treatment or assistance is needed and also improve understanding so that patients and relatives may be suitably supported or helped to adjust.