Home-based models of hospice and palliative care are promoted with the argument that most people prefer to
die at home. We examined the heterogeneity in preferences for home death and explored, for the first time, changes of preference
with illness progression.
We searched for studies on adult preferences for place of care at the end of
life or place of death in MEDLINE (1966-2011), EMBASE (1980-2011), psycINFO (1967-2011), CINAHL (1982-2011), six palliative
care journals (2006-11) and reference lists. Standard criteria were used to grade study quality and evidence strength. Scatter
plots showed the percentage preferring home death amongst patients, lay caregivers and general public, by study quality, year,
weighted by sample size.
210 studies reported preferences of just over 100,000 people from 33 countries,
including 34,021 patients, 19,514 caregivers and 29,926 general public members. 68% of studies with quantitative data were
of low quality; only 76 provided the question used to elicit preferences. There was moderate evidence that most people prefer
a home death-this was found in 75% of studies, 9/14 of those of high quality. Amongst the latter and excluding outliers, home
preference estimates ranged 31% to 87% for patients (9 studies), 25% to 64% for caregivers (5 studies), 49% to 70% for the
public (4 studies). 20% of 1395 patients in 10 studies (2 of high quality) changed their preference, but statistical significance
Controlling for methodological weaknesses, we found evidence that most people prefer
to die at home. Around four fifths of patients did not change preference as their illness progressed. This supports focusing
on home-based care for patients with advanced illness yet urges policy-makers to secure hospice and palliative care elsewhere
for those who think differently or change their mind. Research must be clear on how preferences are elicited. There is an
urgent need for studies examining change of preferences towards death.