Before the widespread availability of acute-care hospital facilities, most deaths occurred at home. Home death rates have declined markedly over the past century [12], averaging approximately 20% for all deaths in the 1990s in developed countries [13]. The past 30 years, however, have seen the development of hospices and palliative care teams and units focused on improving end-of-life care and encouraging people to determine where they wish to die, if possible. Most terminally ill people prefer to die at home rather than in the hospital. This has led to a recent increase in the home death rate in some countries. In the United States, the percentage of home deaths nationally increased from 16 to 23% from the late 1980s to 2001. The rate varied considerably from state to state, ranging from a low of 12.4% in Washington, DC, to a high of 38.4% in Oregon [14]. In some countries, however, including Italy and Japan, a trend toward hospital deaths persisted [15, 16].
For chronically terminally ill patients such as those with advanced cancer, home death rates are higher. Between 1997 and 2003, the percentage of cancer deaths occurring at home in Taiwan was at least 60% [17] and as high as 69%, according to Tang [18]. This rate is higher than those found for other countries, such as the UK (22% in 2003) [19], the US (29–35% in 1994–1998) [19, 20], and Canada (26.3% in 1992–1997) [21].
Dying at home has a special cultural meaning for Chinese patients and their families. Dying in the main hall of one’s own house is known by the Chinese as “dying peacefully in one’s bed.” This is considered to be the most glorious and fortunate manner of death [22]. Thus, “the fallen leaves can return to their roots.” When death occurs at home, the spirit of the deceased can reunite with the forebears and will not be a “koo’un’ia’ kui” (spirit wanderer), a solitary soul with no one on whom to depend. These cultural factors could explain the higher home death rate found in terminally ill patients in Taiwan.
The literature reveals that it is common for terminal-stage cancer patients to die at home. For intensive care patients, however, for whom the primary goal is to treat and cure, going home to die is rare. Many invasive life-supportive treatments and monitors on patients also prevent ICU patients from going home to die at the terminal stage. Only few studies were found regarding going home to die from the ICU. Beuks et al. [5] described two such cases in the Netherlands. Mann et al. [8] and Ryder-Lewis et al. [9] reported on 17 patients (over a 7-year period) and 14 patients (over a 4-year period), respectively, who were taken home from the ICU to be with their families in their last hours in New Zealand. Boussarsar et al. [6] and Kallel et al. [7] also reported their experiences respectively in Tunisia. Among surgical ICU patients at NTUH, however, going home to die at the terminal stage is not uncommon, with rates ranging from 44.1 to 24.6% during the study period of 2003–2007. Apparently, the traditional belief that people should die at home motivated relatives to take patients home from cure-oriented institutions like the ICU when death was imminent.
Many studies have been conducted on factors that influence place of death in terminally ill patients with cancer. We found that older age, lower education level, married status and lack of DNR consent were significantly associated with going home to die from the ICU. Many other studies also reported that older patients were more likely to die at home [14, 17, 23–26]. These findings are in accord with the value placed on dying at home in the Chinese tradition. In contrast to our study, however, Howat et al. [27] found that younger patients were more likely to die at home. They explained that younger patients usually have younger and fitter spouses, along with willing friends and relatives, to aid in their care. In our ICU, however, patients were always taken home by their children. Thus, older age was not a negative factor in going home to die in our study. Lower educational level was also reported to be related to dying at home in other studies [24, 26]. Patients with lower educational levels usually lived in areas characterized by lower socioeconomic levels, where the patients could die at home more conveniently than in modern urban areas. After the patient died, the family usually held a funeral at home. Many studies also found married status to be associated with dying at home [17, 19, 27, 28]. Possible reasons for this finding include that married patients are more likely to have a committed caregiver (the spouse) to provide end-of-life care at home. Paradoxically, the DNR rate of GHTD patients seemed to be significantly lower than that of DICU patients. This meant that GHTD and DNR were not equivalent end-of-life care in our surgical ICU.
Although having religion was not significantly associated with GHTD in our study, we believed that religion and ethnicity had an impact on the patients’ choices of the places of their death. Two of the five exsisting GHTD studies are about Islamic countries [6, 7]. Muslims have a specific conception of death, and the vast majority of them desire to die at home, in their own bed, and to experience some cultural and religious rituals while surrounded by their family and friends [7]. In another study of Mann et al. [8], all 17 patients were Maori or Polynesian. The Chinese tradition also favors people choosing to go home to die at the terminal stage of illness.
However, in our surgical ICU, GHTD patients were not like terminal cancer patients and ICU patients in other countries, for whom going home to die might occur when patients’ conditions were still stable. Our patients were taken home only at their terminal stage, when their blood pressure was very low. At that time, their treatment intensity was even higher than that of DICU patients at the time of death except for MCS and FiO2. It may be that patients with MCS were not allowed to go home to die. The significantly greater use of analgesics and sedatives in GHTD patients may have been due to the desire to make the patients, as well as family members, more comfortable during transport.