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Attitudes and views of physicians and nurses towards cancer patients dying at

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Article  in  Palliative Medicine · April 1997

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Palliative Medicine 1997; 11: 116-126

Miquel Porta Institut Municipal d'lnvestigació Medica, Universitat Autónoma de Barcelona,Xavier Busquet Programa d'Atenció Domiciliaria-Equip de Suport, Institut Catala de la Salut, Manresa andManuel Jariod Institut Municipal d'lnvestigació Medica, Universitat Autónoma de Barcelona

Key words: attitude of health personnel; family; home care services;neoplasms; palliative care

The objective was to study attitudes and views of primary care professionalstowards terminally ill cancer patients who die at home, using a cross-sectional study based in the health district of Manresa (province ofBarcelona, Catalonia, Spain) of the Cataran Health Service, involving 151primary health care professionals (87 physicians and 64 nurses).

By using a self-responded anonymous questionnaire (response rate 89%)it was found that despite excellent motivation, primary care professionalsreported widespread frustration and a poor opinion of the quality of careprovided to terminally ill cancer patients. Attitudes and views clearly differ byage, sex and geographic setting. In the study Brea, most professionals arereluctant to disclose the diagnosis of cancer, and this attitude is associatedwith a more favourable assessment of the support provided to the family.The idea that the most appropriate place of death is at home is stronglylinked to the belief thatpatients ought to be informed of their illness, tofeelings of frustration and to youth. These findings further substantiatethe need and the potential for ample changes in terminal cancer care inSpain.

Mots clés: attitude envers le personnel de la santé; famille; services desoins a domicile; néoplasmes; soins palliatifs

Le but de cette étude était d'analyser les attitudes et opinions desprofessionnels des premiers soins sur les patients incurables atteints d'uncancer qui meurent chez eux. On a utilisé un échantillon de personnes dudistrict de Santé de Manresa (dans la province de Barcelone, en Catalogne.Espagne) qui fait partie du Service de Santé Catalan. Cette étude a compté151 professionnels des premiers soins médicaux (soit 87 médecins et 64infirmieres). En utilisant un questionnaire anonyme (dont le taux de réponseétait 89%) on a trouvé que malgré une motivation excellente lesprofessionnels des premiers soins signalent une frustration générale et unefaible opinion de la qualité des soins donnés aux patients incurables atteintsd'un cancer. Les attitudes et opinions different nettement selon I'age, lesexe et la région. En médecine palliative, la plupart des professionnels sontpeu disposés a divulger le diagnostic du cancer et cette attitude est

Address for correspondence: Dr Miquel Porta, Institut Munici-pal d'Investigació Medica, Universitat Autonoma de Barcelona,Carrer del Dr. Aiguader 80, E-08003 Barcelona, Spain.

@ Arnold 19970269-2163(97)P~OO9()1\

Attitudes and views o/ physicians and nurses towards cancer patients dying at home 117

associée a une évaLuation plus acceptable du soutien fourni a la famille.t:idée que le lieu de la mort le plus approprié est a la maison est fortementliée a I'opinion que les patients devraient ~tre informés de leur maladie. Elleest liée aussi aux sentiments de frustration et a la jeunesse. Ces résultatsjustifient davantage le besoin et le potentiel de grands changements dansles soins pour cancéreux en fin de vie en Espagne.

Introduction Methods

A detailed account of methods has been publishedelsewhere.9 The study was carried out in the healthdistrict of Manresa (province of Barcelona, north-eastern Spain) of the Catalan Health Service. Thedistrict has 156 435 inhabitants and 16.8% of thepopulation over the age of 65. AlI hospital centresin the district are located in the city of Manresa. Theafea is not densely populated (95.4 inhabitants perkm1; 43% of inhabitants live in Manresa city, 49%in a suburban environment and 5% in rural afeas.At the time of the study, no hospital beds wereavailable specifically for palliative treatment and theprimary caTe network was undergoing a process ofreform.l0 The 'reformed primary health caTenetwork' provided caTe for 30% of the population,and the nonreformed (traditional) network for theresto There was one general practitioner per 186inhabitants.

In 1990, opioid analgesics were clearly under-used in the afea: out of a total of 398 patients whodied of cancer, only 26 had narcotic analgesicsprescribed in primary care.u

AlI physicians (n = 87) and nurses (n = 64)employed by the Catalan Health Service in thedistrict for whom attending patients at the patients'homes was part of their professional duties, wereincluded in the study. The questionpaire used wasbased on an extensive review of the literature andwas

developed by consensus of the PADES staff.8,9It was anonymous, and it included 17 closed-endedquestions, most of which were to be answered bychoosing one of tour options of an ordinal nature(see Results); it could be answered in about 5 minoDemographic data collected included age, sex,profession, job situation (permanent contract/non-permanent), whether the health professionalworked

in the reformed primary caTe network, andwhether the afea was rural, suburban or urbano

Field work was carried out by members of thePADES programme between 10 December and 20December 1990. The questionnaire was sent out tophysicians and nurses by internal mail and collected

In Catalonia (northeastem Spain), malignant neo-plasms are the second cause of death among peopleof all ages and the leading cause of potential yearsof life lost.1,2 The emotional strain involved and theattitudes assumed by those caring for terminally illcancer patients can best be understood within thesocial context in which they occur. In Mediterraneancultures, death largely remains a taboo subject, andcancer is associated with a strongly reactive, negativeimage. Thus, the characteristics of the physician-patient-family relationships must be carefullyconsidered by programmes which provide borne caTefor terminally ill patients.3

Many primary health caTe professionals attemptto implement an integrated approach to patientcareo However, the ability to do so in terminally illcancer patients and their families is often under-valued and has received little attention in medicaleducation.4,S In Spain as in other countries, physi-cians often react by being overly frank or insensitive,by becoming distant or avoiding the subject, or bydeciding to prolong treatment long after it is nolonger effective.6,7 In common with other Europeancolleagues, Spanish primary health caTe profession-als regularly attend terminally ill cancer patients.Yet, little information is available on their attitudesand ideas, and studies are commonly restricted tophysicians.

The primary aim of the study was to ascertain thebasic attitudes and views of physicians and nursesworking in fue primary CaTe level of a health districttowards terminally ill cancer patients, in particularwith respect to the following issues: the extent towhich the main aims of palliative treatment (such ascomfort of the patient and support for the family)were achieved, the quality of the relationshipsbetween health CaTe professionals and patients, fueprevalence of feelings of frustration, and the mostsuitable place of death. The survey was carried outprior to the implementation in the afea of a pro-gramme ofhome CaTe and support (namely, PADES'programa d'atenció domiciliaria-equip de suport,).g

118 M Porta et al.

per.sonally a week later at their individual workingplaces or during the course oí a meeting held topresent the new PADES prograrnme.

Statistical analysisNon-normally distributed variables were analysed byMann-Whitney's U-test and the Kruskall-Wallis testfor comparison of two or more groups, respectively.Spearman's rank coefficient (p) was used for corre-lation analysis.12 Confidence intervals ofproportionswere calculated by an exact method. Analysis ofcategorical variables was carried out using contin-gency tables (chi-square test for homogeneity orindependence and chi-square test for linear trend).Logistic regression models were fitted by themaximum likelihood algorithm. The strength of theassociation among variables was calculated throughthe odds ratio (OR) and its 95% confidence inter-val (CI).13 As a qualitative complement of thequantitative analysis, a selection of cornments spon-taneously offered by respondents will here bereported. Analyses were implemented with SPSS-PC+, EPI-INFO and BMDP computer software.

negatively the degree of comfort endured by cancerpatients whom they had treated or followed-up atborne in the previous year (unacceptable 2%, notentirely acceptable 29%, relatively acceptable51 %, acceptable 11 %, no answer (NA) 7%). Profes-sionals were even more critical of the attentiongiven to the family, since 41 % (46% of physiciansand 37% of nurses, P = 0.414) considered it to beunsatisfactory (unacceptable 6%, not entirelyacceptable 35%, relatively acceptable 45%, accept-able 10%, NA 4%).

Older professionals were less critica! than young-er colleagues both regarding the comfort ofpatients (P < 0.03) and family support (P = 0.001).Those that worked in urban afeas were almost threetimes more likely to be critical of support given tothe family iban colleagues working in nonurbanafeas (age and sex-adjusted OR = 2.97, P = 0.007).These findings remained statistically significantwhen fue three types of geographical afea were com-pared: the more rural the environment physiciansand nurses worked in, the more acceptable theyjudged the support given to the family (Figure 1).

Results

Oíthe 151 questionnaires sent, 135 were completed,thus yielding an overalI response late oí 89%. Theresponse in the urban environment was lower thanin rural afeas (77% vs 100%, P < 0.001). The meanage oí proíessionals surveyed was 40.1 years (stan-dard deviation: 10.1). Eighty-twowere physicians and53 (39%) were nurses. Overall, 57% were women(39% oí the physicians). The women were signifi-cantly younger than the men (P < 0.001). A nonper-manent position was held by 38% oí respondents;three out oí tour respondents with a nonpermanentcontract were women. Fifty-two per cent oí proíes-sionals reported that in the previous year they treatedor íollowed-up at borne three or more terminalIy i11cancel patients. Significantly more cases wereattended by older personnel (P = 0.011), byproíessionals with permanent contracts (P = 0.004),and by those working in nonurban afeas (P = 0.001).

Information to tbe patientMost respondents said tbat patients sbould not beinformed of tbeir diagnosis (never 4%, excep-tionally 56%, usually 33%, always 2%, NA 6%).Sixty-one per cent oí physicians and 66% of nurses(P = 0.734) said patients sbould never or excep-tionally be informed. Written comments on thisitem included 'it depends' (on the personality or ageof the patient, on the family situation) and '1 thinkpatients should be informed of their illness, but tbeyare not normally informed'.

Only 28% of men said that the patient shouldusually or always know bis or her diagnosis, ascompared to 73% ofwomen; thus men were almosttour times less in favour of disclosure than women(OR = 3.92, CI: 1.69-9.33, P < 0.001) (Jable 1).Professionals who said that the patient should not beinformed were more likely to have a permanentcontract and tended to rate more favourably thesupport provided to the family (OR = 1.83,P > 0.15 in both cases). There were no statisticaldifferences with respect to age, profession, geograph-ic setting, number of terminally ill cancer patientstreated or followed-up at borne in the previous year,opinion on cornfort of patient, feeling of frustrationand difficulties of relationship with patients.

Comfort for the patient and support of thefamilyThirty-one per cent of professionals (31 % of physi-cians and 37% of nurses, P = 0.651) assessed

Attitudes and views of physicians and nurses towards cancer patients dying at home 119

80%

60%cn

"¡ij1::o"00cna>

ea."6a>O!!tSCa>u

Q¡a.

40%

20%

0%

Urban Suburban Rural

Figure 1 Professionals' assessment of support provided to the family of terminal cancer patients, according to geographical

setting

Even after adjusting by age, difficulties in rela-tionships, and opinion on family support, womenremained ayer three times more predisposed toinform patients than men (OR = 3.38, CI:1.40-8.17, P = 0.007).

year (P < 0.20). A positive assessment of the sup-port provided to families was weakly associated withhaVing no problems (OR = 2.2, CI: 0.86-5.61, P =0.15). Frustration was also slightly less commonamong professionals who never or exceptionallyexperienced difficulties (P = 0.25).

After adjusting by sex, age retained its predictivevalue: the chances of having difficulties in therelationships with patients decreased by 8% withevery increase in one year in the age of theprofessional (OR = 1.08, CI: 1.00-1.17, P = 0.04).The Tole of sex receded when age was taken intoaccount, so that the relative risk of difficulties ofwomen dropped to 2.54 (CI: 0.81-7.99, P = 0.11).Professionals reporting difficulties were somewhatmore prone to disclosing the diagnosis (OR = 1.5,CI: 0.58-3.91, P = 0.56); ibis effect disappearedwhen age and sex were accounted for (P = 0.873).

Relationships with the patientAn equal proportion of physicians and of nurses(83% ) reported that they had never or exceptionallyexperienced difficulties of relationship with termi-nally ill cancer patients. Overall, 34% said they hadnever experienced difficulties, 46% exceptionally,14% usually, and 2% always (NA 4%). Commentswere often made that difficulties arase when

.patients had not been informed of the nature of" their illness.

Difficulties in the relationship with patients werealmost tour times more likely to be reported by

.women than by men (OR = 3.80, CI: 1.31-11.04,P < 0.02) (Table 2). There was an inverse relation-ship between the age of the health professional andthe experiencing of difficulties (p = 0.297,P<O.OOl); in particular, professionals younger than35 years reported many more problems. Difficultiesalso tended to relate inversely with the number ofterminally ill subjects cared for during the previous

Feelings of frustrationA majority of subjects (50% of physicians and 60%of nurses, P = 0.373) reported that caring forterminal cancel patients made them feel frustrated(always 16%, often 35%, sometimes 41%, never3%, NA 5%). Spontaneous comments pointed to'the system' as the main cause of frustration; fre-

120 M Porta et al.

Table 1 Variables related with disclosure of the diagnosis of cancer

Never/exceptionally

(%)

Always/usually

(%)

DA 95% CIn P value

Age (years):<3535--4445-54>54

4245

,1517

la1.653.641.67

29.739.216.214.9

44.435.66.7

13.3

O.274bO.159cO.O85d

0.64-4.270.78-19.10.45-6.28

Profession:PhysicianNurse

8047

61.238.8

1"1.23

66.034.0 0.54-2.81

4879

32.567.5

1"1.83

46.853.2

Job

situation:NonpermanentPermanent contract O.157b0.87-3.83

Geographic setting:UrbanNonurban

5077

36.363.8

1"1.42

44.755.3 0.68-2.96

Patients attended last year:None1-23-5>5

18435412

10.035.045.010.0

,82.332.502.50

23.131.938.38.5

0.373b0.181c0.21~

0.66--8.340.74-8.540.44-15.4

Family support:NonappropriateAppropriate

5270

37.562.5

52.447.6

1a1.83 O.166b0.86--3.90

Comfort of patient:UnacceptableAcceptable

4080

32.167.9

35.764.3

181.18 O.83gb0.53-2.60

Frustration:NoVes

5367

42.957.1

46.553.5

181.16 0.55-2.45

Difficulties 01 relationship:VesNo

21102

15.085.0

20.979.1

1"1.50 O.560b0.58-3.91

OR: odds ratio = odds of never or exceptionally informing the patient versus odds of always or usually doing so. CI: confidenceintervaloaReference category. bZ2 test. CMantel-Haenszel Z2 test for linear trend. dMann-Whitney's U-test.

quently mentioned were bureaucracy (particularlywith regard to access to narcotic analgesics), and theisolation of primary health care professionals,especially in rural afeas.

Women were twice as likely as men to report f.eel-ings of frustration (OR = 2.27, CI: 1.11-4.54, P =0.04) (Table 3). Inverse and statistically significant

associations were found with age (P = 0.012) andwith the number of cases attended in the previousyear (P < 0.04); ibis latter result held after adjustingby age (OR = 2.18, CI: 1.00-4.74, P = 0.049).

Multivariate analysis showed that professionalswho had attended two or less terminal patients inthe previous year were twice as likely to experience

Attitudes and views 01 physicians and nurses towards cancer patients dying at home 121

rabie 2 Variables related with difficulties 01 relationship with the patients

Never/exceptionally

(%)

DA 95%CI P valueAlways/usually

(%)

,"3.80

6862

47.252.8

77.322.7 O.O19b1.31-11.04

,"2.826.077.80

43451519

29.738.613.917.8

61.928.64.84.8

O.O34b0.003c0.007d

0.86-10.040.74-275.90.98-349.6

,8'.05

5278

39.860.2

40.959.1 1.000b0.41-2.66

1"1.92

4882

34.365.7

50.050.0 O.24gb0.76-4.84

181.13

5080

38.062.0

40.959.1 O.985b0.44-2.88

18

2.792.616.00

15465613

9.336.143.511.1

22.731.840.94.5

0.286b0.132c0.180d

0.56-12.720.55-11.020.51-306.9

,"2.20

5573

39.660.4

59.140.9 O.l49b0.86-5.61

Sex:WomenMen

Age (years)::J <35

35-44.45-54

>54, Profession:-Nurse

Physician

Job situation:NonpermanentPermanent contract

Geographic setting:UrbanNonurban

Patients attended last year:None1-23-5>5

Family support:NonappropriateAppropriate

Comfort of patient:UnacceptableAcceptable

Frustration:VesNo

1"1.79

4283

31.468.6

45.055.0 O.35Sb0.68-4.72

51.948.1

1"1.98

6957

68.231.8 O.248b0.68-5.91

c~

OR: odds ratio = odds of never or exceptionally experiencing difficulties versus odds of always or usually doing so.CI: confidence intervalo"Reference category. bX;2 test. cMann-Whitney's U-test. dMantel-Haenszel X;2 test for linear trend.

patients of their illness (P = 0.005), as well as withfrustration (P = 0.0015). Multivariate analysesshowed that believing that patients ought to beinformed of their illness, reporting frustration, andage, when rnutually adjusted for, were statisticallyindependent predictors of the opinion that the rnostappropriate place of death was at borne (Table 4).When the professionals were asked where theywould like to die in case of severe, terminal illness,the percentage who chose 'at borne' increased frorn62% to 71 %, and the percentage who recornmend-ed centres for long-term caTe decreased frorn 19%

írustration than colleagues who treated three or'. more patients (OR = 2.08, CI: 0.92-4.71, P =

0.()78). The influence of sex (P = 0.313) and age (P= 0.157) were considerably reduced in multivariate

~ analyses.

Place of deathSixty-two percent of respondents (61 % of physiciansand 64% of nurses, P = 0.71) considered that thernost suitable place for fuese patients to stay and diewas the patient's own borne (Figure 2} This view wasstrongly associated with readiness towards informing

122

M Porta el al.

Table 3 Variables related with the feeling of frustration

Never/exceptionally

(%)

ORAlways/'usually

(%)

95%C.i P value

6266

39.160.9

59.340.7

1a2.27 1.11-4.54

43441518

45.328.115.610.9

25.046.48.9

19.6

1"0.330.970.31

0.033b0.10400.012d

0.13-0.870.24-4.320.08-1.11

7652

55..144.9

1"1.48

64.435.6 O.373b0.68-3.21

8048

58.042.0

67.832.2

1"1.53 O.336b0.74-3.15

1a1.44

8147

59.440.6

67.832.2 0.69-2.98

,"0.720.4'0.28

16445513

15.939.137.77.2

8.528.849.213.6

0.201 b

O.O34c0.032d

0.17-'-2.780.10-1.500.05-1.66

7153

54.445.6

60.739.3 O.601b1.29 0.63-2.63

,8'.73

8041

60.639.4

72.727.3 0.80-3.75

Sex:WomenMen

Age (years):<3535-4445-54>54

Profession:PhysicianNurse

Job situation:Permanent contractNonpermanent

Geographic setting:NonurbanUrban

Patients attended last year:None1-23-5>5

Family support:AppropriateNonappropriateComfort of patient:AcceptableNot acceptable

Difficulties of relationship:NoVes

1"1.98

10422

78.321.7

87.712.3 O.248b0.75-5.27

OR: odds ratio = odds of always or usually feeling frustrationversus odds of never or exceptionally feeling frustration.CI: confidence intervalo"Reference category. bX2 test. cMann-Whitney's U-test. dMantel-Haenszel X2 U-test for linear trend.

to 4% (Figure 2). Among the youngest professionalsDone selected acute-care hospitals. Nurses selectedthe borne option more often than physicians (84% vs73%) when referring to their own death, and Donechose acute-care hospitals. A greater number ofphysicians were unsure (19%) and, as opposed tonurses, considered acute-care hospitals more appro-priate than centres for long-term caTe (P = 0.019).

was based on a self -administered questionnairewhose validity and reliability have not been formallyassessed; secondly, the design was cross-sectionaland, hence, cannot detect changes in attitude or '

definitely establish causality; and thirdly, the size ofthe study population was relatively small.

Given that OUT overall response rate (89%) r

was very high when compared with similarstudies,6,7,14-16 'participation bias,17 seems unlikely.Although the type of survey (direct contact andshort questionnaire) might seem to explain the highlevel of participation, ayear and a half later aresponse rate of only 40% was obtained in a surveyon domiciliary oxygen therapy in the same reference

Discussion

In the interpretation oí the results several studylimitations must be borne in mind: first, the study

Attitudes and views 01 physicians and nurses towards cancer patients dying at home 123

nosis?0-22 Resistance to informing patients23 hasbeen also observed in other Mediterranean coun-tries,24,25 where a 'wall of silence' around the patientis often built; this can cause significant strain in thefamily,26,27 and it may also disturb the professional'sjob, Difficulties may increase when caTe is providedin the patient's home?8

Cornments from respondents showed a certaincontradiction between what 'is' and what 'shouldbe', In London, Haines and Booroff14 found thatwhilst 50% of general practitioners were in favourof patients being informed of the diagnosis, 89%recognized that they never, or almost never,informed patients of their illness.

The age of physicians and nurses, or the birthcohort to which they belonged, strongly influencedattitudes and views. It is possible that youngerprofessionals were more fearful of death?9 Theywere also more critical of the caTe provided. Thegreater inclination of women to disclose diagnosismay be related to cultural and psychological factors,since age, profession, geographical location, andorganization did not influence this finding. Womenoften appear to show more sensitivity towards thepsychosocial aspects of death.3o They also have beenseen to experience higher levels of anxiety in the

population and using a similar procedure. In thepresent study, the high level of participation sug-gests that there is real interest in the subject, andalso that primary caTe professionals considerterminal caTe for cancer patients an important andchallenging part of their work.

Despite such a high degree of motivation, profes-sionals have difficulties in attaining the main objec-tives of palliative caTe, such as provision of comfortfor the patient and support to the family. Surveyparticipants underlined the importance of trainingand organizational issues, in particular access tomorphine and coordination with the hospital.9,18But feelings of frustration were also strongly linked(inversely) to the number of cases attended. Otherstudies have found that those who caTe for moreterminally ill patients have fewer problems dealingwith their own emotional strain and with that of thepatient and family.15

Communication between professionals and thefamilies of the patients has been identified as a criti-cal aspect in caring for terminal patients. Recentstudies have reported that over 40% of patients whohad not been informed about their illness did notwant more information19; Jet, in most cases thepatient suspects, knows, or wants to know the diag-

80%

60%U)

"¡ijco

.00U)aJ"6o.."6aJO)<1S

EaJ~aJc..

40%

20%

0%Home Acute care

hospitalChronic care

hospitalNo answer

Figure 2 Opinion of professionals regarding the suitable place of death for terminally ill cancer patients

124 M Porta et al.

Table 4 Variables related to the view that the most suitable place for terminally ill cancer patients to die is at. home.Multivariate logistic regression analysis.

Variable DA 95% CI P valueD__=_.- :_,--_tJ ~ ~ Prone to inform 5.99 1.42-25.32 0.015

Feeling of frustrationC 3.83 1.10-13.30 0.035Patient relationshipsd 2.40 0.38-14.97 0.349Work in reformed PHCe 1.93 0.50-7.39 0.338Work in urban settingt 1.07 0.32-3.54 0.911Uses majar analgesics9 1.98 0.43-9.03 0.380Ageh 1.11 1.04-1.18 <0.001

"AII variables are mutually adjusted foro i.e. the model included sIl seven variables.bprone to disclose diagnosis to patient versus not prone.cFeeling of frustration versus no feeling of frustration.dDifficulties of relationship versus no difficulties.eworking in reformed Primary Health Care network versus working in nonreformednetworktUrban setting versus suburban and rural settings.9Never used majar analgesics versus ever (in terminal cancer patients).hper every year younger.

probably explain the fact that no nurses wished todie in hospital. This was the only significant differ-ence in attitude between nurses and doctors.

The results also indicate that an effort is neededto educate health professionals in the psychosocialaspects of terminal CaTe for cancer patients, topromote the participation of social workers withinhealth caTe teams, and to facilitate access topsychologic services in primary careo Overall, webelieve the reported findings further substantiatethe need and the potential for great change interminal CaTe in Spain.

AcknowledgementsWe are grateful to the all physicians and nurses ofprimary caTe of the Manresa health district, for par-ticipating in the study. To colleagues from PADES-Manresa and to the district health authorities, forencouragement and support. To colleagues atHospital de la Santa Creu de Vic, especially to DrJordi Roca, for comments to the questionnaire. ToNúria Malats, J Lluís Piñol, Esteve Femandez andM Cruz Molina for scientific advice. To PuriBarbas, Helena Martínez and David Macfarlane fortechnical help. And to Marta Pulido for valuableassistance in preparing an earlier version of themanuscript. The analysis of the present study waspartly funded by the Fondo de InvestigaciónSanitaria (grant 92/0311), Madrid, Spain and by theGeneralitat de Catalunya (CIRIT/SGR 434).

presence of death.31 Women who were more fear-fuI of death have shown greater willingness todisclose the diagnosis.z9

Differences between urban and rural environ-ments have received little attention in the field ofterminal cancer. A Tole is probably played by theavailability of and attitudes towards health servicesin urban and rural areas.z2 Differences in howdeath is experienced in the city and in the countryshould algo be considered. The present results differfrom those obtained in a study in which ruralphysicians in Australia reported more problemsdealing with the emotional distress of familiesthan physicians in urban afeas (74% versus 53%,P = 0.04).15

Complex factors determine the place of death ofcancer patients.z2,32,33 According to respondents ofthis survey the family home is the best place for suchpatients to die. This coincides with preferences ofthe ma~ori~ of the population, both ill andhealthy. 4-36 In Zaragoza, Spain, it was found that

persons who would not like to be informed of theirillness more often chose their home as place ofdeath.z1 But this choice does not necessarily meanthat professional pallia~ive caTe will be provided athome; for example, patients with an attitude ofdenial were common among late admissions to aprogramme of palliative caTe at home in London.37The different function of and relation with acute-caTe centres that physicians and nurses have, would

Attitudes and views 01 physicians and nurses towards cancer patients dying at home 125

References 17 Porta M, Belloc J, Malats N. Estudios españolessobre la demora diagnóstica y terapéutica en elcáncer. Un análisis crítico de su metodología yresultados. In: Porta Serra M, Alvarez-Dardet C,eds. Revisiones en salud pública, vol. 1. Barcelona:Masson, 1989: 197-226.

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