Delivering preference for place of death in a specialist palliative care setting

Abstract

Over the last 10 years, one of the key themes of public policy in palliative care has been achievement of choice in place of death.In Marie Curie Hospice Edinburgh a baseline audit conducted in 2006 showed that only a small proportion (18%) of patients referred to hospice services died at home. The audit also revealed that only 31% of those who expressed a preference to die at home were able to do so, whereas 91% of those who chose a setting other than home achieved their preference. Overall achievement of preferred place of death was 56%. However a significant number of patients (29%) did not have a recorded preference.A programme of quality improvement has continued over the last 7 years to improve identification, communication and achievement of preferred place of death for all patients. The mechanisms to change practice have been: changes to documentation; changes to clinical systems to support use of documentation; support for clinical staff to recognise the value of discussing preferences; and support for clinical staff to develop new skills. In addition the programme has been incorporated into local clinical strategy and this has enabled gaps in service to be addressed with a new service to support early discharge of those patients who wish to die at home.A recent audit showed that all patients had a recorded preference or a documented reason why their preference was unclarified. One third of patients died at home – nearly double the proportion that died at home in the baseline audit. Seventy one per cent of patients who wished to die at home actually died at home – a substantial increase from 31% at baseline. Achievement of preferred place of death for patients wishing to die in the hospice remained high at 88%.The focus on assessment of preference for place of death has led to substantial improvements in the identification and achievement of preference for patients dying under the care of the hospice. Furthermore, it has been associated with an increase in the overall proportion of patients who die at home.

The Right Place at the Right Time: Medical Oncology Outpatients' Perceptions of Location of End-of-Life Care

“…10 Onethird of patients indicated a preference for receiving care in a hospice/palliative unit. This proportion is higher than reported in studies conducted a decade ago, 11,15 which may reflect a growing recognition of the availability and potential benefits of these services among patients with cancer, 16,17 and be a result of increasing efforts to integrate oncology and PC services. 18 Although more than half of Australians die in hospitals, only one-fifth of patients selected the hospital as their most preferred location of care.…”

‘Being a conduit’ between hospital and home: stakeholders' views and perceptions of a nurse‐led Palliative Care Discharge Facilitator Service in an acute hospital setting

“…A study by Oxenham et al . () which examined hospice patients' willingness to express their end‐of‐life preferences found that when approached, 78% of patients were able to express a preferred place of death (PPD). In the same study, patients who had an unknown PPD were three times more likely to die in hospital.…”

“…Alonso-Babarro et al (2011) affirms this by stating that initiating simple conversations around end-of-life care could facilitate the achievement of the preferred place of care. A study by Oxenham et al (2013) which examined hospice patients' willingness to express their end-of-life preferences found that when approached, 78% of patients were able to express a preferred place of death (PPD). In the same study, patients who had an unknown PPD were three times more likely to die in hospital.…”

Do medical oncology patients and their support persons agree about end‐of‐life issues?

“…Support persons need to be involved in discussions to ascertain agreement between both parties and establish the feasibility of achieving preferences. Improved communication about patients’ preferred place of death may significantly increase the likelihood that preferences are achieved …”

“…Improved communication about patients' preferred place of death may significantly increase the likelihood that preferences are achieved. 26,27 Some people prefer an active role in all aspects of endof-life decision-making (i.e. personal control), while others prefer a more passive role, relying on providers and/or support persons to decide (i.e.…”