For long, it has been believed that people prefer to die at home-or in the community-rather than in hospital, although the evidence available is not conclusive (Hoare et al, 2015). Dying when surrounded by one's friends and loved ones is an understandable preference, rather than with medical staff in attendance in a sterile hospital environment. Having said that, care in hospital at the end of life does afford some advantages, including ease of administering pain relief, managing acute palliative symptoms or providing specialist palliative care for those who require it. The NHS Long Term Plan (NHS England, 2019) also made a case for improving end-of-life care overall but especially in the community setting. High-quality community palliative care improves outcomes for patients and carers while also keeping costs for the NHS low, by ensuring hospital avoidance.
The year of the pandemic brought with it drastic changes in how healthcare is viewed and delivered, and one of the interesting outcomes has been the increase in home deaths during this time, from causes other than COVID-19 (the top causes being cancer, dementia and heart disease). In England and Wales, deaths in people's own homes, from all causes, were higher by around 33% in 2020 (167 000) than in the previous 5 years (125 000). This difference was even more marked for the population aged 85 years and over: some 144 000 people died in the community (care homes and private homes), compared with 89 000 people who died in hospital.
Writing on the King's Fund blog on 8 June 2021, Veena Raleigh analysed the data relating to the excess deaths that occurred at home in 2020 (Raleigh, 2021). Various reasons for this were cited, including that:
While these data could be viewed as a positive, the quality of these excess deaths that occurred at home-especially with regard to the provision of adequate pain relief at the end of life-is yet to be determined. Like all healthcare service providers, community palliative nursing services were greatly impacted by the pandemic, and staff and resources around the country were stretched thin. Further, despite the recognised benefits of community-based palliative care, this service remains poorly coordinated. These data also need to be analysed to determine what proportion of those who died at home actually made their desire to do so explicit in their care plans (Raleigh, 2021), and family experiences of these deaths need to be investigated.
What the pandemic has shown us is that it is possible to ensure that people remain at home in the last days of life. Further analysis of the data and caregiver experience will determine how sustainable this will be in the post-pandemic world.