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

BMJ 2006; 332 doi: (Published 02 March 2006) Cite this as: BMJ 2006;332:515

This article has a correction. Please see:

  1. Barbara Gomes, research associate (barbara.gomes_da_silva{at},
  2. Irene J Higginson, scientific director1
  1. 1 The Cicely Saunders Foundation/Department of Palliative Care, Policy, and Rehabilitation, King's College London, London SE5 9RJ
  1. Correspondence to: B Gomes
  • Accepted 24 December 2005


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 ne 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.


  • Embedded Image Details of the full search strategy, including key words (table A), the quality assessment scale, three extra tables (of high (table B), medium (table C), and low (table D) quality studies), and full references for all identified studies are on

    We thank the Cicely Saunders Foundation; Denise Brady, librarian at St Christopher's Hospice, for her advice on the search strategy; Cathy Shipman, who critically reviewed the study proposal; Harvey Chochinov, Richard Harding, and Stephen Barclay for their comments on an earlier draft. A special thanks to Dame Cicely Saunders for her always insightful views.

  • Contributors IJH conceived the idea for the study and obtained funding. BG conducted the searches, identifying and retrieved studies, and extracted the data. Both authors developed the methods and the model, assessed the quality of studies, conducted the analysis, interpreted the data, wrote the report, and are guarantors.

  • Funding The Cicely Saunders Foundation.

  • Competing interests None declared.

  • Ethical approval Not required.

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