Academic journal article Population

In France, Where Do People Live in Their Last Month of Life and Where Do They Die?

Academic journal article Population

In France, Where Do People Live in Their Last Month of Life and Where Do They Die?

Article excerpt

Most deaths in France today occur at advanced or very advanced ages. This is a recent phenomenon in human history, observed only since the twentieth century and only in countries where particularly good progress has been made in combating death and disease. Life expectancy in France has increased continuously since 1945 and stood at 78 years for men and 84.6 years for women in 2010. Mortality from birth to care age is now so low that gains in life expectancy are essentially due to declining mortality at advanced ages (Prioux, 2006). This raises the question of whether a new health transition is possible, based especially on closer attention to the day-to-day needs of those in the oldest age groups as a means to further prolong their lives (Vallin and Meslé, 2010).

These changes in mortality patterns are associated with radical changes over the past 50 years in the settings within which people die. The dying process has progressively moved from the private to the public sphere. In 1950 most people died at home, and a majority still did so until the mid-1970s. Since then, institutions, mainly hospitals, have assumed a much larger role (Aouba et al., 2008). In 2009, 58% of deaths in France took place in hospital, 26% at home and 12% in care homes (with or without nursing) (Beaumel and Pla, 2012). France is in an intermediate position among European countries in this regard: in the Netherlands 34% of deaths take place in hospital and 62% in Sweden (Lalande and Veber, 2009; Observatoire national de la fin de vie, 2012).

The proportion of people dying in hospital has remained fairly stable since 1990, while the proportion of home deaths has declined slightly and care home deaths have increased (Monnier and Pennec, 2004; Observatoire national de la fin de vie, 2012). But dying in hospital does not mean that the entire end- of-life trajectory takes place there. There is an abundant literature on place and cause of death, but the circumstances in which people spend the last weeks of their life has rarely been investigated in France. Elsewhere, researchers have revealed a wide range of end-of-life trajectories, the most common being a move from home to hospital (Abarshi et al., 2010), and shown the impact of patients' level of independence (Weitzen et al., 2003) and their pathology (Houttekier et al., 2010a, 2010b) on their end-of-life residential trajectory (Escobar Pinzon et al., 2011; Pennec et al., 2012a). As a rule, people with cancer are more likely than other categories to be cared for in hospital, and those with mental disorders in care homes. Other studies have analysed the impact of socio-demographic factors on the likelihood of spending one's last days in this or that type of setting (Gisquet et al., 2012). While there are large variations between countries (Cohen et al., 2006; Gomes, Higginson et al., 2012), many studies have concluded that family care - particularly by the spouse - has a major influence on the likelihood of dying at home (Escobar Pinzon et al., 2011; Gomes and Higginson, 2006; Houttekier et al., 2011).

The "Fin de vie en France" (End of Life in France) survey, conducted in 2010 (Pennec et al., 2012a, 2012b), addresses these issues for France, describing residential trajectories during the last month of life, along with associated factors. The survey was conducted among physicians who had signed death certificates and provided the necessary data to establish end-of-life trajectories, i.e. place of residence 28 days, 7 days and 1 day before death, and on the day of death. At this stage of life, the places of departure and arrival - home, hospital, care home - are determined by the choices and constraints of the patients and their families and carers. This article examines whether certain demographic or medical factors (age, sex, cause of death, symptoms observed, purpose of treatment, etc.) are associated with particular end-of-life trajectories. What differentiates those who spend their last month of life in familiar surroundings (at home or in a care home) from those who are hospitalized? …

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