Hospital at home: home-based end of life care

  • Comment
  • Review
  • Intervention

Authors


Abstract

Background

The policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and patients with a terminal illness would prefer to receive end of life care at home.

Objectives

To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) to October 2009, Ovid MEDLINE(R) 1950 to March 2011, EMBASE 1980 to October 2009, CINAHL 1982 to October 2009 and EconLit to October 2009. We checked the reference lists of articles identified for potentially relevant articles.

Selection criteria

Randomised controlled trials, interrupted time series or controlled before and after studies evaluating the effectiveness of home-based end of life care with inpatient hospital or hospice care for people aged 18 years and older.

Data collection and analysis

Two authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible we presented the data in narrative summary tables.

Main results

We included four trials in this review. Those receiving home-based end of life care were statistically significantly more likely to die at home compared with those receiving usual care (RR 1.33, 95% CI 1.14 to 1.55, P = 0.0002; Chi 2 = 1.72, df = 2, P = 0.42, I2 = 0% (three trials; N=652)). We detected no statistically significant differences for functional status (measured by the Barthel Index), psychological well-being or cognitive status, between patients receiving home-based end of life care compared with those receiving standard care (which included inpatient care). Admission to hospital while receiving home-based end of life care varied between trials and this was reflected by high levels of statistically significant heterogeneity in this analysis. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on care givers.

Authors' conclusions

The evidence included in this review supports the use of end of life home-care programmes for increasing the number of patients who will die at home, although the numbers of patients being admitted to hospital while receiving end of life care should be monitored. Future research should also systematically assess the impact of end of life home care on care givers.

摘要

家中的醫院:家庭導向的生命末期照護

背景

在許多國家中的政策是要提供末期疾病的民眾有居家等待生命結束的選擇。此政策由調查所支持,顯示出一般大眾及末期疾病病患會偏好居家中等待生命的結束。

目的

想要決定提供家庭導向的生命末期照護是否能降低在醫院中等候死亡的可能性,以及這對病患的症狀、生活品質、健康服務成本以及與住院醫療或是臨終關懷照護相比的照護提供人員上的效果如何。

搜尋策略

我們搜尋了考科藍對照試驗的中央註冊(CENTRAL)(The Cochrane Library)至2009年10月、 OVID MEDLINE (R) 1950至2011年3月、EMBASE 1980年至2009年10月、CINAHL 1982年到2009年10月以及ECONLIT到2009年10月。我們檢查了所找出文章的參考清單以利提供可能的相關文章。

選擇標準

隨機對照試驗、中斷性時間序列或受控的事前事後研究評估了年滿18歲及以上者,進行家庭導向生命末期照護、住院病患或是臨終關懷照護的有效性。

資料收集與分析

兩位作者獨立的摘錄數據並評研究品質。我們利用混合效果的M-H統合分析,分析二分法結果的文獻。當無法合併數據分析時,我們以表格呈現數據進行總結概要說明。

主要結果

我們在此審閱中包含了4個試驗。這些接受家庭導向生命末期照護者在統計上明顯的更有可能於家中死亡,其係與接受一般照護者比較(RR 1.33,95% CI 1.14到1.55,P=0.0002;Chi 2 = 1.72,df = 2,P = 0.42,I2 = 0%(3個試驗;N=652))。就功能性狀態(由Barthel指數測量)、心理幸福感或認知狀態而言,在接受家庭導向生命末期照護病患間與接受標準照護(包含住院照護)者比較,我們沒有偵測到統計上顯著的差異。入住醫院同時接受家庭導向生命末期照護在試驗間各有不同,這由此分析中統計上顯著的高度異質性所反應。由某些證據顯示接受家庭導向生命末期照護病患的滿意度增加,且有些微的證據顯示此形態的照護對照護提供者有所影響。

作者結論

此審閱中所包含的證據支持生命末期家庭照護計畫的使用,因為居家死亡的病患人數逐漸增加,雖然病患獲得入住醫院同時接受生命末期照護的數量也應監控。未來的研究也應系統性的評估生命末期居家照護對於照護提供者的影響。

Plain language summary

Home-based end of life care

A number of countries have invested in health services to provide care at home to patients with a terminal illness who wish to die at home. This investment is backed by surveys of the preferences of the general public and patients with a terminal illness, which indicate that most people would prefer to receive end of life care at home. We systematically reviewed the literature to see if the provision of end of life home care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care. We included four trials in our review and report that the provision of end of life home care does increase the probability of dying at home. However, it is not clear if this also results in more people being transferred to hospital during this phase of their illness. There are few data on the impact these services have on family members and lay care givers.

淺顯易懂的口語結論

家庭導向的生命中末期照護

許多國家都調查了提供想要於家中死亡末期疾病病患家庭照護的醫療保健服務。此調查由一般大眾及患有末期疾病病患的偏好調查所支持,其指出,大多數民眾偏好於家中接受生命末期照護。我們系統性的審閱文獻,觀察生命末期家庭照護的提供是否減少了在醫院中等候死亡的機率以及其在病患症狀、生命品質、健康服務成本以及與住院或臨終關懷照護相比在照護提供者上有何影響。我們在審閱中納入了4個試驗,並指出生命末期家庭照護的提供確實增加了於家中等候死亡的機率。然而,並不確定這是否導致更多人於此疾病階段被轉送到醫院。這些服務對相關家庭成員與提供照護服務者的影響數據,很少有研究資料。

譯註

翻譯: East Asian Cochrane Alliance
翻譯補助: 台灣衛生福利部/台北醫學大學實證醫學研究中心

Ancillary