The UK government has marked place of death as a key indicator for the quality of end of life care. This is based on the idea that most people would prefer to die at home, but the evidence for this is not as strong as previously thought, argues Kristian Pollock from the University of Nottingham in The BMJ this week.
She writes that “focusing on place of death as the key indicator of quality in end of life care distracts attention from the experience of dying, ” and calls for “more attention and resources to be spent on improving end of life care wherever this occurs, in hospitals or elsewhere.”
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Dr. Pollock argues that more research is needed regarding what matters most to people at the end of life. For example, the difference between people’s preference regarding place of care, as opposed to place of death, is often overlooked.
In addition, she says a preference to die at home does not mean that place of death is the highest priority. Evidence suggests that dying in pain is the greatest concern of patients and the public, and that pain is less well controlled at home.
Idealised accounts of ‘the good death’ at home often do not recognise the reality of the pain and discomfort experienced by some dying patients, she adds. “The person may have been alone, inadequately supported, in pain, distressed, and fearful.”
Hospitals have become widely regarded as inappropriate and undesirable places to die, she explains. There are concerns about poor quality of care and the high costs incurred by deaths in hospital.
However, hospitals may be preferred by patients who see them as places of safety and effective control of symptoms, especially for those who suffer distress and pain. Many patients wish to avoid imposing a burden on their families and may prefer to transfer responsibility for care from home to hospital, she says.
She adds that it is important to recognise and accommodate the diversity of patient preferences for place of death.
“When patients wish to die at home, every effort should be made to achieve this outcome. However, until resources are in place to adequately and equitably support home deaths, the current promotion of patient choice risks raising expectations that are not realised”, she says.
Dr. Pollock concludes that as hospitals will remain the most common place of death for the foreseeable future, instead of “neglecting and disregarding the hospital as a site of terminal care, much greater thought and adequate resources must be directed to enabling hospitals to provide excellent support for dying patients and their families.”
