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

Abstract

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.

Fig 1

Algorithm for grading the strength of evidence. High quality studies had performed multivariate analysis and had a quality score of ≥70%; medium quality studies had multivariate analysis but a quality score of <70% or did not have multivariate analysis but had a quality score of ≥60%; and low quality studies had no multivariate analysis and a quality score of <60%. This method of grading evidence was based on a previous system used on risk factors, similar to the SORT taxonomy, a patient centred approach to grading evidence. To increase the methodological quality and robustness of the findings we raised the level for considering high quality scores for individual studies and high consistency of findings from 50% to 70%; said that high quality studies had to have used multivariate analysis; took high strength evidence exclusively from high quality studies; and required a minimum of three high quality or three medium quality studies about a topic

Fig 2

Flow of studies through review

Fig 3

Factors with high strength evidence from 15 studies. Each point represents results on one study, except when study provided ranges, when both odds ratios are shown. Numbers indicate minimum and maximum odds ratios for each variable

Fig 4

Model of variations of place of death