# Reasons for and Congruence Between Preferred and Actual Place of Death Among Cancer Patients Receiving End-of-Life Care: A Cross-Cultural Multicenter Prospective Cohort Study in East Asia

## TL;DR

This study explores why cancer patients in East Asia prefer to die at home but often end up dying in hospitals, highlighting cultural and systemic factors affecting end-of-life care.

## Contribution

The study is the first large cross-cultural cohort analysis of place of death congruence in East Asia, revealing insights into cultural and systemic barriers to goal-concordant care.

## Key findings

- Most terminally ill cancer patients in East Asia die in hospitals or hospices despite some preferring home death.
- Cultural traditions, family influence, and housing situations significantly affect place of death decisions.
- High congruence rates are observed for institutional deaths, but home death congruence remains low.

## Abstract

Place of death reflects not only personal choice but also the quality and accessibility of care, as well as culturally specific factors like family-centered decision-making in East Asia. This study followed over 2600 terminally ill cancer patients admitted to palliative care units in Japan, Korea, and Taiwan. We found that while 13–22% of these patients still preferred to die at home, the majority (82–96%) ultimately died in hospitals or hospices. Even within specialized palliative care, the congruence between the preferred and actual place of death was high (70–80%) only for institutional deaths, while home death rarely occurred. Family opinions, cultural traditions, and housing situations often play a strong role in shaping these outcomes. This first large cross-cultural cohort study deepens our understanding of clinical- and system-level barriers to goal-concordant care and provides actionable insights for improving communication, transitional planning, and community support in East Asian healthcare systems.

Background/Objectives: The place where a person dies serves as an indicator of end-of-life care quality. This study aims to identify the congruence of place of death (POD) and the reasons behind decision-making among terminally ill cancer patients in East Asia. Methods: We conducted a prospective multicenter cohort study in palliative care units in Japan, Korea, and Taiwan. Data were collected by the responsible physicians during routine clinical practice. Sankey diagrams were applied to present changes in reasons for POD incongruence. Results: A total of 2638 participants from 37 palliative care units in the three countries were enrolled, and most of them died at PCUs (Japan: 95.7%, Korea: 94%, Taiwan: 82%, p < 0.05). The congruence rate of the preferred and actual POD among PCU inpatients ranged from 70% to 80%. Availability of end-of-life care is the most common reason for preferred and eventual PCU death (78.6%, 72.2%, and 52.1%, respectively, p < 0.05). However, 13–22% of patients admitted to PCUs still preferred to die at home, for which traditional culture (20.2%, 40.8%, and 82%, respectively, p < 0.05) or family influence (44.4%, 38.8%, and 51.7%, respectively, p > 0.05) are the main reasons. Cultural and environmental factors, such as influences from family members’ preferences in the three countries or the ownership of housing/housing settings in Japan, are the main challenges in achieving POD congruence. Conclusions: Culturally inclusive strategies in clinical practice and policy implementation for identifying the preferred POD, enhancing communication among stakeholders, and facilitating transitional support may improve the quality of goal-concordant care.