BMJ 1999;319:1472-1475 ( 4 December )

General Practice

Does hospital at home for palliative care facilitate death at home? Randomised controlled trial

Editorial by Keeley

Gunn E Grande, research associate,  Chris J Todd, director of Health Services Research Group,  Stephen I G Barclay, GP Macmillan facilitator,  Morag C Farquhar, research nurse. 

Health Services Research Group, General Practice and Primary Care Research Unit, Department of Community Medicine, University of Cambridge, Institute of Public Health, Cambridge CB2 2SR

Correspondence to: G E Grande geg1001{at}medschl.cam.ac.uk

Objective: To evaluate the impact on place of death of a hospital at home service for palliative care.
Design: Pragmatic randomised controlled trial.
Setting: Former Cambridge health district.
Participants: 229 patients referred to the hospital at home service; 43 randomised to control group (standard care), 186 randomised to hospital at home.
Intervention: Hospital at home versus standard care.
Main outcome measures: Place of death.
Results: Twenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deaths at home. Seventy three patients randomised to hospital at home were not admitted to the service. Patients admitted to hospital at home were significantly more likely to die at home (88/113; 78%) than control patients. It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service. The study attained less statistical power than initially planned.
Conclusion: In a locality with good provision of standard community care we could not show that hospital at home allowed more patients to die at home, although neither does the study refute this. Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult. While these difficulties have to be recognised they are not insurmountable with the appropriate resourcing and setting.


Key messages

  • Terminally ill patients allocated to hospital at home were no more likely to die at home than patients receiving standard care

  • Although the subsample of patients actually admitted to hospital at home did show a significant increase in likelihood of dying at home, whether this was due to the service itself or the characteristics of patients admitted to hospital at home could not be determined

  • The need to balance ideal research design against the realities of evaluation of palliative care had the effect that the trial achieved less statistical power than originally planned

  • Particular problems were that many patients failed to receive the allocated intervention because of the unpredictable nature of terminal illness, inclusion of other service input alongside hospital at home, and the wide range of standard care available

  • The trial illustrated problems associated with randomised controlled trials in palliative care, none of which are insurmountable but which require careful consideration and resourcing before future trials are planned




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