Do home palliative care services have an impact on where people die?

As in many other developed countries, the UK population is rapidly ageing. This has implications for the provision of health and social care, as older age and life-limiting, chronic conditions are closely linked. There is a growing need for palliative care.

One of the key values of palliative care is to enable people to choose where to be cared for at the end of life. When asked for their preferences, around two thirds of people choose to die at home.

The number of home deaths is now increasing in England, in part due to an End of Life Care Strategy (2008-13) focused on making this happen. However, the increase has been relatively slow, from 18.1 per cent home deaths in 2003 to 21.8 per cent in 2011.

In order to help increase further the number of people who are able to die at home, we took the challenge of conducting a Cochrane review to quantify the impact that home palliative care services have on death at home and other outcomes for adult patients with an advanced illness and their family caregivers.

These findings justify strengthening investment in home palliative care services in the UK, including the development of home palliative care services in national health policies and programmes

It was also important to review the evidence on the cost-effectiveness of these services. Cochrane reviews represent the highest level of evidence on which to base clinical treatment decisions.

So what did we find? We reviewed research findings from 37,561 patients and 4,042 family caregivers from the UK, USA, Sweden, Norway, Italy, Spain, Canada and Australia. We found robust evidence from meta-analysis that home palliative care services double the odds of home death when compared to usual care (odds ratio 2.21).

We calculated numbers needed to treat to benefit (NNTB) and found that for one additional person to die at home, five more need to receive home palliative care.

In addition, based on narrative synthesis we found evidence that home palliative care services reduce symptom burden for patients without impacting on caregivers’ grief intensity, when compared to usual care. The evidence on cost-effectiveness is inconclusive.

This review is important because it shows clear and reliable evidence of benefits from home palliative care services in increasing the odds of home death and reducing patients’ symptom burden.

These findings justify strengthening investment in home palliative care services in the UK, including the development of home palliative care services in national health policies and programmes.

Of course, there are still things we need to know better. Full economic evaluations are scarce and the evidence on cost-effectiveness inconclusive – we need more of these types of studies. We also need to assess the impact on family caregivers, who are crucial partners in the provision of care towards the end of life, especially at home.

Randomised controlled trials (RCTs) are considered to be the gold standard in research assessing the effectiveness of services and treatments. This type of study is particularly difficult to do in palliative care. Nevertheless, we identified six RCTs that were of high quality in our review. This shows it is possible to conduct good RCTs in palliative care; hence we call for more to be developed.

High quality studies will help us build further evidence in areas where the findings remain inconclusive, with a view to inform policy and practice and provide the best care for patients and their families.

Natalia Calanzani is a researcher at the Cicely Saunders Institute, King's College London, working with Professor Irene Higginson and Dr Barbara Gomes in a long-standing project in order to understand where and how people die, and their preferences at the end of life. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.