January 19, 2012
UK Death In A Home Setting On The Rise
Although around two thirds of us would prefer to die at home, in the developed world the trend in recent years has been for the majority to spend their final days in an institutional setting. But according to new research available in the journal Palliative Medicine, published by SAGE and from King's College London, the tide has now turned and an increasing number of people in the UK are dying at home.
In England and Wales, the number of deaths at home nearly halved from 1974 to 2003. If this trend continued, researchers projected that fewer than one in ten would die at home by 2030. Barbara Gomes, Natalia Calanzani and Irene Higginson from the Cicely Saunders Institute based at King's College London, intended to find out if this trend had persisted. This project is part of a program of research examining place of end of life care and death. In this study, the researchers analyzed death registration data from the UK Office for National Statistics for all those who had died between 2004 and 2010 — over 3.5 million records.
The team found that, following trends in the USA and Canada, dying at home is now also becoming more prevalent in Britain. This was the case both for the absolute number of individuals, and as a proportion of the total: In 2004 there were 93,907 deaths at home (representing 18.3% of total deaths). This increased to 102,416 in 2010 (20.8% of total deaths). The increase in absolute numbers of home deaths is ever more important as the annual number of total deaths went down 3.8% from 2004 to 2010.
The rise in home deaths was more pronounced among those with cancer. Home deaths also increased for the first time since 1974 amongst people aged 85 years and over (from 17,122 in 2004 to 23,705 in 2010). Even so, those aged 85 and over died less often at home over the seven-year period than any other adult age groups.
"What seemed to be an enormous task has happened - the reversal of the British longstanding trend towards an institutionalized dying," said lead author Gomes from King's. "From 2004 onwards, it became more common for people in England and Wales to die at home."
The program of research carried out by the Cicely Saunders Institute at King's, supported by the charity Cicely Saunders International, has been followed for a number of years by policy makers, both nationally and internationally. The British policy push towards enabling more people to die at home used previous research from the King's team to underpin the government end-of-life care program (established in 2004) and the national end-of-life care strategy (published in 2008). Now it seems these policies may be contributing to this trend reversal. "We are seeing here how research can improve patient care at the end of life" explained Professor Higginson, Director of the Cicely Saunders Institute. "Our earlier work, also published in Palliative Medicine, drew attention to the gaps between preferences and actuality, which changed Government policy, leading to greater emphasis on meeting patient preferences. The good news is that the policies seem to be working, although the UK has a lot of variation still."
Despite this shift, the proportion of home deaths still remains low compared with the USA, Canada and some other European countries (e.g. the Netherlands). The most recent figure (20.8%) still has a long way to go before the preferences of the majority of people who wish to die at home are met.
Britain is also unusual in that the overall number of deaths has recently been decreasing, but is forecast to rise substantially in the near future according to Office for National Statistics population projections. This will be accompanied by an increased demand for end-of-life care. It remains to be seen whether the trend towards more individuals dying at home will continue as this shift takes place. Even though more of the very elderly are dying at home based on these ONS statistics, the most elderly in Britain continue to have fewer chances to die at home than other age group.
Even for those who do die at home, little evidence has been gathered to establish whether they, and their relatives, experience better care than those who die in institutions such as hospitals, hospices or nursing homes. "There is an urgent need across nations for comparative evidence on the outcomes and the costs of dying at home, work which the charity Cicely Saunders International is supporting." Gomes concludes.
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