What's needed for terminally ill patients to die at home?
Factors influencing death at home in terminally ill patients with cancer: Systematic review; BMJ Volume 332, pp 515-8Family support and better home-based care are two of the key priorities needed to enable terminally ill cancer patients to die at home, say researchers in this week's BMJ.
The study, by a team at King's College London, follows the recent announcement by the UK government to shift the emphasis of care from acute hospitals to primary care.
Well over half of people with a progressive illness want to die at home and several countries, including the UK, are making substantial reforms to enhance home care. But despite these efforts, most people in the UK, the US, Germany, Switzerland, and France die in hospitals. In the UK, the proportion of home deaths for patients with cancer is falling, from 27% in 1994 to 22% in 2003.
To determine what factors influence where patients with cancer die, the researchers analysed 58 studies involving over 1.5 million patients from 13 countries.
The most important factors linked to dying at home were patients' limited function and mobility, patients' preferences, availability and level of home care, presence of live-in relatives, and extended family support.
Future policies to enable people to die at home should focus on empowering families, public education, and improving home care, say the authors. Risk assessment and training doctors in end of life care are also important priorities.
In the last three years the UK has invested £12m in its end-of-life care programme but has so far failed to stop the trend of hospital deaths. Professor Higginson explains: "We have compared the current policies of the Government with the results of our review. All of the actions the Government is recommending and funding in its end-of-life care programme fall short in some ways.
In particular, they are not paying enough attention to assessing who is at risk of experiencing problems, in supporting families and in educating people about what they can expect from care. In Canada they have a new system of providing compassionate leave - like maternity leave - for carers, and perhaps the government needs to think of something like that in addition to ensuring home support."
"This model represents an evidence based answer to the rights of terminally ill patients to die at home with dignity," says author, Barbara Gomes. "We strongly encourage its use in the development and evaluation of future strategies by policy makers to enable more home deaths and by practitioners to enable their patients to die at home if they wish so."
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