Although many patients prefer to spend their final days at home, the reality in Brazil is quite different. A study analyzing places of death from cancer in 12 Latin American countries shows that Brazil leads in hospital deaths: 80.6% of cases, well above the regional average of 65.3%.

The place of death is an important indicator of the quality of end-of-life care. In countries such as Canada and the Scandinavian nations — recognized for palliative care with structured assistance, standardized coverage, and accessible public systems — a high rate of home deaths can be seen as a positive signal. But this is not the case in contexts like Brazil.

“In middle- and low-income countries, this is usually a negative social determinant — and a very negative one. In Brazil, counting home deaths is essentially counting patients with cancer who die almost without care,” Jessé Lopes da Silva, MD, PhD, oncologist and researcher at the Brazilian National Cancer Institute in Rio de Janeiro, Brazil, told Medscape’s Portuguese edition.

He is the lead author of a study published in The Lancet Regional Health, which points to home deaths in Brazil as a reflection of the weaknesses in the public health system.

The research analyzed cancer deaths in Brazil over nearly two decades (2002-2021). During this period, 82.3% of deaths occurred in hospitals. But, according to da Silva, the most revealing figure is the 17.7% who died at home — a proportion that increased during the COVID-19 pandemic. “Oncology patients were denied access to health services. It was a disastrous situation,” he recalled.

Even today, in much of Latin America, dying at home is less a matter of choice and more a sign of exclusion from the healthcare system.

Data show significant regional disparities in Brazil. Home deaths were most frequent in the Northeast (30.2%) and North (24.8%) regions, while the South (17.1%) and Southeast (12.2%) fell below the national average. The analysis found a strong inverse correlation between the proportion of home deaths and the Human Development Index (HDI) of the regions — the lower the HDI, the higher the frequency of deaths outside hospitals.

Although all states recorded an increase in hospital deaths during the period, only nine states and the Federal District also saw growth in home deaths.

“The reality for patients dying at home, often without adequate medication or any support, is that this generates even more suffering for the individual and the family accompanying the terminal process,” said da Silva.

In Brazil, where about 80% of patients with cancer are treated through the public health system, the problem of access goes beyond the availability of healthcare services, noted Maria Del Pilar Estevez Diz, MD, PhD, medical director and clinical oncology coordinator at the Instituto do Câncer do Estado de São Paulo (ICESP) in São Paulo, in an interview with Medscape’s Portuguese edition. “Sometimes, the barrier is transportation.”

The patient profile also reveals a pattern different from that observed in Europe. While in European countries people with higher education tend to die more at home — having more resources and autonomy to decide where to spend their final days — in Latin America, except for Argentina, the opposite occurs: Individuals with more years of schooling are more likely to die in hospitals.

The explanation may lie in the location of specialized services. In the region, palliative care is still concentrated in hospitals, which makes the choice of place of death, when possible, lean toward where better care is available: the hospital.

Challenges and Solutions

Not all patients in exclusive palliative care require highly complex interventions. However, most cases demand intensive support from a multidisciplinary team with specialized training, capable of providing effective pain management and continuous monitoring.

“This level of care cannot always be guaranteed at home, unless there is a specialized palliative care team integrated with the oncologist and the hospital, able to visit the patient periodically,” explained Estevez Diz.

One potential solution, she said, would be to integrate palliative care into primary care teams, such as those in Brazil’s Family Health Strategy or the “Melhor em Casa” (“Better at Home”) Program, an initiative of the publicly funded Unified Health System that delivers care through multidisciplinary home care teams. However, challenges remain, including adequate training for these teams and reliable access to strong pain medications.

In 2024, Brazil’s Ministry of Health launched the National Palliative Care Policy, aiming to train and qualify 1300 teams to provide home-based care. The initiative envisions these specialized teams serving as technical references, supporting and training other healthcare professionals caring for patients who require palliative care, with the goal of delivering support that is both effective and humane.

Both Estevez Diz and da Silva consider the policy a significant step forward. “Places that are already better prepared will implement the program more quickly. In others, implementation will be slower,” said Estevez Diz. For da Silva, the policy can have a positive impact when widely implemented, but for now, Brazil still lacks a well-structured program with broad national coverage to ensure quality end-of-life care.

Despite its potential, adoption is still low. As of July 2025, only 24 proposals for team qualification had been submitted to the Ministry of Health, and 14 were approved. “We expected 100-200 proposals. We need to broaden understanding across regions [about the importance of palliative care],” said Mariana Borges Dias, general coordinator of Home Care and Palliative Care at the Ministry, during a meeting in São Paulo on the policy’s implementation.

The main technical obstacles include:

• Unequal access to medications, such as opioids and oxygen therapy.
• Lack of adequate funding.
• Shortage of trained professionals.
• Limitations in medical prescription systems.

“In the public system, there are isolated programs aimed at specific populations. In the health insurance sector, some plans have well-structured palliative care teams, but this is not the rule,” noted da Silva.

Another barrier to patients remaining at home until the end of life is the need for family members available to provide 24-hour care. But, according to specialists, this alone is not enough: caregivers must be trained and receive continuous professional support.

A promising practice, already adopted by the ICESP team, is remote care via video calls, which has been well received by families. This tool allows professionals to see the patient’s environment, answer specific questions, and adapt care to the home setting. “However, this practice is not yet systematized in Brazil,” explained Estevez Diz.

Finally, issuing a death certificate can be a decisive hurdle. In cases of natural death with medical care, ideally the attending physician — preferably the one who followed the patient — should go to the home to confirm the death and issue the certificate. Without a team prepared to provide this service 24/7, the process is complicated. As Estevez Diz noted, if the doctor does not attend, the family must file a police report and contact the death verification service, which is more complex.

“Very often, the patient expresses the desire to stay at home until the end. But when death is near and a physician is not available to issue the certificate, the family ends up taking the patient to the hospital to avoid this situation,” explained Estevez Diz.

From the Doctors’ Perspective

Accompanying patients in the terminal phase during exclusive palliative care is a complex task. According to Estevez Diz, this process requires more than technical knowledge: physicians need to be prepared to communicate calmly, recognize the limits of medicine, and accept the natural course of disease. “It’s essential to understand that there comes a point when it’s not a professional’s failure but the progression of the illness and limitations of knowledge. Physicians need the maturity to recognize this. In my opinion, if they can’t, it’s very difficult for the family to understand it as well.”

Although exclusive palliative care has legal backing and a clear technical definition, the process must be agreed upon with patients and their families. Yet not everyone is ready to accept this moment. Many are still in stages of denial or anger about the illness. “Even the multidisciplinary team accompanying the patient needs time to process that therapeutically, everything possible has already been done, and now it’s time to focus on comfort,” said Estevez Diz.

Dehospitalization also requires guarantees of a care network and continuous support. For da Silva, this is a real challenge. “It’s hard work, and often the easier path is chosen.” He noted that untrained physicians tend to avoid the emotional and logistical effort involved in organizing end-of-life care outside hospitals.

Despite guidance from the Brazilian Medical Ethics Code — which allows avoiding invasive procedures, unnecessary diagnostics, or treatments when there is no prospect of cure — many professionals continue to keep patients hospitalized, often without clearly communicating the prognosis to families or preparing them for death realistically.

Earlier in his career, da Silva accompanied patients on home visits to ensure they could die at home. Over time, the work became more complex: setting up home hospitalization required a hospital bed, a supportive mattress, medications, intravenous therapy, and spiritual support. Families and patients prepared together for the farewell. “Accompanying a well-supported home death is deeply rewarding. It provides genuine comfort for those leaving and for those who remain,” he reflected.

Hospices: A Less Explored Option

Between dying at home and dying in a hospital, there is a third option that is little explored in Brazil: hospices. These institutions provide care focused on comfort, dignity, and emotional support for patients and families through specialized multidisciplinary teams.

“Even with legislation recognizing them, hospices are still not widespread in Brazil,” said Estevez Diz. She cited examples such as ICESP’s hospice units, the São Paulo State Public Servant Hospital, and a few private institutions.

As of 2024, Brazil had 373 such units, concentrated mainly in the South and Southeast regions. A major milestone came in January 2025 with the opening of the country’s first public palliative care hospital: Mont Serrat State Hospital, in Salvador. The facility does not have an ICU or resuscitation room but provides specialized pain management and grief support for patients and families.

Patients’ Preferences

Preferences for place of death remain understudied in Brazil. A survey conducted in Brazil between 2019 and 2021 with 190 patients with advanced cancer and their caregivers found that 77% of patients and 74% of caregivers preferred dying at home — provided home care was available. However, when accounting for the possibility of severe or uncomfortable symptoms, only 17.4% of patients maintained that preference.

Estevez Diz highlighted the distinction between “wanting to die at home” and “being able to remain at home until the end.” Patients often return to hospitals during critical moments. Those able to stay home generally have a strong family network, structured support, and sufficient financial resources. “Even so, many do not feel confident receiving care at home, especially when dealing with severe pain or other challenging symptoms. Teams trained for home visits make all the difference,” she said.

Da Silva emphasized that, even with adequate infrastructure, it is essential to listen to the patient and family. “This moment requires weighing many factors: personal experiences, cultural aspects, and religious beliefs.”

Relationship With Death

“We don’t deal well with death; our culture has fostered fear of it within our homes,” da Silva noted. The experience of terminal illness in Brazil is marked by extremes: some patients receive excessive interventions, while others die without basic care.

Historically, death has shifted from the family or community sphere to hospitals. Today, the end of life often occurs in medical facilities, sometimes under inhumane conditions. Experts argue that rediscovering the value of death, recognizing it as a natural part of life, and providing it with the care it deserves could be the first step toward transforming the dying experience in Brazil.

This story was translated from Medscape’s Portuguese edition.