Introduction
The majority of people are thought to want to die at home, however more than 50% of the UK population die in hospital.1,2 Government initiatives in the UK strive to improve equitably the quality of care received by patients and encourage the individual to choose and receive the care necessary to experience death in their preferred place.3,4
Specialist palliative care in the community is often delivered by voluntary sector organisations. Local commissioning arrangements consider quality markers that they recognise against funding provided to such services. In Wales, place of death is considered a quality marker by the commissioners of this palliative care service. This audit compares the actual place of death patients experienced against their preferences.
Method
A proforma was completed upon the death of every patient referred to the service in 2009. The information captured included the preferred and actual place of death, aspects surrounding their end-of-life care and the reasons for admission for those individuals who died as hospice inpatients or in secondary care.
Results
During 2009, 346 patients known to the hospice died, the median number of days patients were known to the service was 71 and the mean 154 days. The most common cancer diagnoses among those patients referred were lung, colon, pancreas and breast.
Fifty-eight per cent of patients specified that their preferred place of death was their current place of living (including home, residential or nursing home, and prison). Of patients who expressed this preference, 65% were able to achieve this. Eighteen per cent identified that they would prefer to be admitted as an inpatient to the hospice for end-of-life care and 85% achieved this preference. Two per cent of patients identified that they wanted to be admitted to secondary care and no preference was identified in the remainder. During the course of their illness, 55 patients (16%) changed their expressed preference. Further information concerning patients who were admitted for end-of-life care and did not achieve their expressed preferences is outlined in Table 1. Seven per cent of deaths were from patients referred for non-malignant disease; 15 out of 23 of these achieved their preferences for end-of-life care.
Triggers for admission in the patients admitted for end of life care who did not achieve their expressed preferences. Number of events in brackets.
Discussion
The proportion of patients achieving their preferences for home and inpatient hospice with this community service compares favourably with those results reported nationally and in other studies.1,2 Despite the often unpredictable time course5 for patients with non malignant disease the majority of these patients were able to achieve their preferences for end-of-life care.
Review of information collected upon a patient's death enabled the service to present basic information to their commissioners for discussion. The breakdown of information by primary care team and cause of admission enabled the service to consider targets for future areas of education and activity to facilitate more individuals achieving their preferences for end-of-life care. The number of patients who die at home could potentially be increased if the events which triggered acute admissions are considered as starting points to change health professional behaviour and target social care. Achieving preferences for end-of-life care are not events which occur in isolation in the community. It involves the primary care team, out of hour's service, local palliative care service and communication with secondary care specialists. Success is a reflection of healthy community services, and not a marker of quality for community teams.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2011 Royal College of Physicians
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