Is Choice a Reality for People at the End of Life?

A number of surveys of the general population have shown that, if we had the choice, most of us would prefer to die at home if we were terminally ill.

A number of surveys of the general population have shown that, if we had the choice, most of us would prefer to die at home if we were terminally ill. The results change slightly if you ask only people who are already ill or older where they would prefer to die. Hospice care becomes an increasingly popular choice for both groups. The consistent message, however, is that dying in hospital is what people least want.

The reality is that the majority of people who die continue to die in hospital. Successive governments have sought to reverse this, not only to ensure that more people can be better cared for and supported in the last days of their lives, but to also reduce the pressure on the limited resources of hospitals.

There has been moderate success in supporting people to die at home in recent years. The rate of deaths at home has increased slightly (18.3% - 20.8%) from 2004 to 2010 after a long decline in the last quarter of the 20th century. But is this enough?

When putting in place the most recent reforms of the NHS in England, the coalition government indicated it wanted to go further and faster. It announced that it was seeking to introduce a 'national choice offer', under which anyone who chose to die at home would be supported to do so. Before implementing this policy, the coalition government committed to reviewing the capacity of the health and social care system to deliver this promise.

The numbers don't look good. While the number of people dying at home is increasing, we also know that more of us are living longer. While this is good news, it also means that many more of us in the future will be living with multiple conditions and will have increased hospital usage. When we reach the end of life the complexity of these conditions mean we are more likely to be admitted to and die in hospital.

Today, the Nuffield Trust has published a study on the Marie Curie Nursing Service, which shows that Marie Curie's patients are more likely to die at home and less likely to use hospital when they are at the end of life.

The study examined the outcomes of nearly 30,000 patients cared for by the Marie Curie Nursing Service and also looked at a 'control' group of patients who received standard care. More than three quarters (77%) of those who received MCNS care died at home, while only 8% died in hospital. In contrast, 35% of the control group died at home while 42% died in hospital.

The results are wonderful news for Marie Curie, but the story is much bigger. The study demonstrates that a good quality home-based nursing service that follows the Marie Curie model can reduce hospital use at the end of life and help more people to die at home.

This helps us see much clearer what needs to be done if we are to make dying in place of choice a reality for the majority of people at the end of life. Politicians of all parties and at both local and national level should now be supporting the use of home and community based palliative care services for people at the end of the life. What the evidence shows is that this is a proven way to support people who are terminally ill to be cared for and die in the place they want to be. It also shows that home-based nursing services are a powerful tool to start relieving pressure on the NHS as it begins to deal with consequences of an ageing population.