A palliative-care intervention and death at home: a cluster randomised trial

doi:10.1016/S0140-6736(00)02678-7

The Lancet

Volume 356, Issue 9233, 9 September 2000, Pages 888-893

https://doi.org/10.1016/S0140-6736(00)02678-7 Get rights and content

Summary

Background

The Palliative Medicine Unit at University Hospital of Trondheim, Norway, started an intervention programme that aims to enable patients to spend more time at home and die there if they prefer. Close cooperation was needed with the community health-care professionals, who acted as the principal formal caregivers, and a multidisciplinary consultant team coordinated the care. We did a cluster randomised trial to assess the intervention's effectiveness compared with conventional care

Methods

Community health-care districts in and around Trondheim, Norway, were defined as the clusters to be randomised. We enrolled 434 patients (235 assigned intervention and 199 conventional care [controls]) in these districts who had incurable malignant disease and an expected survival of 2–9 months. Main outcomes were place of death and time spent in institutions in the last month of life.

Findings

395 patients died. Of these, more intervention patients than controls died at home (54 [25%] vs 26 [15%], p<0·05). The time spent at home was not significantly increased, although intervention patients spent a smaller proportion of time in nursing homes in the last month of life than did controls (7–2 vs 14–6%, p<0–05). Hospital use was similar in the two groups.

Interpretation

The palliative-care intervention enabled more patients to die at home. More resources for care in the home (palliative care training and staff) and an increased focus on use of nursing homes would be necessary, however, to increase time at home and reduce hospital admissions.

Introduction

In many more-developed countries, a major proportion of cancer deaths occur in institutions,1, 2, 3 although results from population-based surveys and studies among terminally ill patients suggest a preference for dying at home.4, 5, 6 In palliative medicine, care that enables patients to remain and eventually die at home has been put forward as an ideal.⁷ A wide range of palliative-care programmes, including home care, has been developed.7, 8, 9 Few, however, have been assessed by randomised trials,10, 11, 12, 13, 14, 15 and the methods of most trials that have been done have been criticised.16, 17 Documentation of the effectiveness in reducing deaths and inpatient time are scarce.17, 18, 19 Existing evidence comes almost exclusively from the USA and UK, and relies heavily on observational or comparative non-randomised studies in selected groups of patients.17, 18, 19 As the number of cancer deaths and the demands on limited hospital resources increase,2, 9 home-care services for the terminally ill attract growing attention. An urgent need for further research into effectiveness has been expressed.¹⁷

The Palliative Medicine Unit at the University Hospital of Trondheim, Norway, was the first unit in Norway to start a palliative-care programme, including inpatient and outpatient services. We did a cluster randomised trial to assess its effect compared with conventional care. We tested the hypothesis that the intervention programme would increase the rate of home deaths and the amount of time spent at home.

Section snippets

Setting

We did the trial in the Norwegian Public Health Service, which provides hospital and community care. Eight local-community health-care districts participated. The six districts of Trondheim city (141 000 inhabitants) are geographically defined independent units, and the two neighbouring districts, Malvik (10 000 inhabitants) and Melhus (13 000 inhabitants), are rural communities. Despite minor variations, the community services are similar in all the districts,²⁰ and include family physicians,

Results

From March, 1995, until the end of the trial in November, 1997, 434 of 707 referred patients were included—235 intervention patients and 199 controls (figure 1).²³ In the clusters, the intervention and control groups consisted of 134 and 116, 77 and 65, and 24 and 18 patients, respectively, with the smallest numbers of patients in the rural pair.

At baseline, patients differed for housing, access to informal help, home-care nursing, and, slightly, for living situation (table 1). Diagnoses were

Discussion

The palliative-care intervention enables more patients to die at home. We found, however, no evidence of an increase in the overall proportion of time spent at home, which is consistent with reports from some earlier randomised controlled trials,11, 13, 14 whereas others have found a significant reduction in the number of inpatient days.10, 12

In accordance with palliative-care philosophy, home care and death at home were judged favourable outcomes and the main points of interest. However, we

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ArticlesA palliative-care intervention and death at home: a cluster randomised trial

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Setting

Results

Discussion

Soc Sci Med

J Chronic Dis

Lancet

Eur J Cancer

Where do cancer patients die? Ten-year trends in the place of death of cancer patients in England

Palliat Med

Attitudes to some aspects of death and dying, living wills and substituted health care decision-making in South Australia: public opinion survey for a parliamentary select committee

Palliat Med

Preferred versus actual place of death: a hospital palliative care support team experience

Palliat Med

Terminal cancer care and patients' preference for place of death: a prospective study

BMJ

Death at home: challenges for the family and directions for the future

J Palliat Care

Evidence based palliative care

BMJ

A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients

Palliat Med

A randomized controlled study of a home health care team

Am J Public Health

A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill

Health Serv Res

Articles
A palliative-care intervention and death at home: a cluster randomised trial