BMJ, doi: 10.1136/bmj.38740.614954.55, (Published 8 February 2006)

RESEARCH

Factors influencing death at home in terminally ill patients with cancer: systematic review

Barbara Gomes 1* Irene J Higginson 1

1 The Cicely Saunders Foundation/Department of Palliative Care, Policy, and Rehabilitation, King's College London, London SE5 9RJ

* Correspondence to: barbara.gomes_da_silva{at}kcl.ac.uk.

Objectives To determine the relative influence of different factors on place of death in patients with cancer.

Data sources Four electronic databases--Medline (1966-2004), PsycINFO (1972-2004), CINAHL (1982-2004), and ASSIA (1987-2004); previous contacts with key experts; hand search of six relevant journals.

Review methods We generated a conceptual model, against which studies were analysed. Included studies had original data on risk factors for place of death among patients, >80% of whom had cancer. Strength of evidence was assigned according to the quantity and quality of studies and consistency of findings. Odds ratios for home death were plotted for factors with high strength evidence.

Results 58 studies were included, with over 1.5 million patients from 13 countries. There was high strength evidence for the effect of 17 factors on place of death, of which six were strongly associated with home death: patients' low functional status (odds ratios range 2.29-11.1), their preferences (2.19-8.38), home care (1.37-5.1) and its intensity (1.06-8.65), living with relatives (1.78-7.85), and extended family support (2.28-5.47). The risk factors covered all groups of the model: related to illness, the individual, and the environment (healthcare input and social support), the latter found to be the most important.

Conclusions The network of factors that influence where patients with cancer die is complicated. Future policies and clinical practice should focus on ways of empowering families and public education, as well as intensifying home care, risk assessment, and training practitioners in end of life care.

(Accepted 24 December 2005)
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