br Discussion The place of death is viewed as a

Discussion The place of death is viewed as a factor affecting the quality of end-of-life care in developed countries. It has been reported to vary depending on socioeconomic status, availability of health-care resources, and cultural background. In Europe, reports from Germany, Belgium, and Ireland have demonstrated an increasing trend of dying in an institution (hospice or nursing home), although dying in hospital still accounts for the majority of cases. In Mexico, however, as many as 52.9% of patients die at home, with deficiencies in health-care resources, advanced age, and suburban/rural residence being the predictive factors. Similar influencing factors have also been reported in Germany, Belgium, The Netherlands, and England. Support from NS-398 Supplier and improved health-care resources have been reported to be beneficial for those dying at home. Enabling people to choose where they die is an important issue for high-quality end-of-life care. A previous study reported that most terminal patients consider their home as the preferred place of death. Therefore, expanding and improving palliative care at home may improve the quality of care and prevent unnecessary hospitalizations. However, few terminal patients actually die at home. Between 1990 and 1997, Tang and McCorkle found that 84–88% of terminal patients preferred to die at home, but only 17% actually did in 1995; the factors for this are unclear. The main purpose of this study was to identify the relevant characteristics of places of death in terminal patients. In Taiwan, several population-based studies have discussed this issue. Tang et al performed a 6-year nationwide analysis of cancer patients, and found that most died in hospital. Lin et al investigated the role of the area of residence in the place of death, and found that, among the elderly and cancer patients, a low urbanized area was associated with dying at home. Both studies also suggested expanding the availability of palliative home care and hospice care to allow more patients to die at home. In the present study, patients with IDD had an older mean age (≥60 years), which is consistent with the finding of a previous population-based study. Interestingly, the proportion of patients aged 80 years and older was similar in both groups (19.8% vs. 19.2%). Further comparing the patients\' mean age and type of hospices for terminal admission, those admitted to a DOH/municipal hospital and veterans\' hospital had the highest mean age (71.1±13.5 years and 67.2±15.6 years, respectively). This may be because many elderly patients aged 80 years and over in Taiwan originally came to Taiwan during the Chinese Civil War in 1949, and many were servicemen. In 2014, the veterans accounted for 19.9% of all octogenarian deaths in Taiwan. These patients are more likely to use DOH/municipal hospitals and veterans\' hospitals, and thus in-hospice death is a more logical choice. The distribution of the types of cancer is also interesting. Theoretically, the type of cancer should not have impact on a patient\'s place of death, and the rate should be approximately the same in both groups. However, a previous population-based study in Taiwan reported that respiratory tract cancer was a predictor for dying at home. In this study, patients with IDD had relatively higher rates of gastrointestinal/peritoneal cancer and pulmonary cancer, although the differences did not achieve statistical significance. The reason for these findings is unclear, although it may be due to more severe conditions, advanced age, and different referral times in those with specific types of cancer. Further investigations are warranted to elucidate this issue. In this study, most cancer patients were treated at family medicine and oncology/hematology departments, and included more patients with IDD than those who died in a hospice. These two departments are more familiar with both hospice care and supporting IDD. Other departments also promoted the choice of IDD for terminal cancer patients after hospice care (Table 4). Paradoxically, radiation oncology was the first department to introduce hospice care in Taiwan, however, it had a higher rate of patients dying in hospice rather than with IDD. The possible reasons may be that palliative radiotherapy prolongs life and hospital stay, and reduces late referrals. The lower availability of palliative home care service may also be a factor. A study conducted in central Taiwan reported that palliative home care allowed more terminal patients to die at home. However, radiation oncology provides hospice ward care combined with palliative radiotherapy, which may influence the actual place of death for terminal cancer patients. Compared with the DOH/municipal hospitals, the religious corporation hospitals had the highest positive OR for patients with IDD. A possible reason for this is that religious corporation hospitals place great emphasis on hospice care, providing more hospice home care and more spiritual care workers for terminal patients, and promote public education about palliative care. The negative correlation of IDD with oropharyngeal cancer, bone/connective tissue/breast cancers, and metastatic cancers may reflect difficulties in palliative home care for these cancers, such as wound management, feeding, and pain control. A longer hospice stay may also reflect similar difficulties, especially for those with terminal oropharyngeal cancer who had the longest mean hospice stay (12.9±12.5 days). The correlation between male sex and dying in a hospice may reflect gender-specific types of cancer and the male predominance in certain groups (such as veterans). Professional training for palliative home care and relevant education for patients\' families may overcome these issues.