In spite of the major therapeutic advances for all kinds of diseases, poor survival rates remain an obstacle. Therefore, a large portion of terminal patients are destined to eventually die from their diseases.
It has been reported that more than half of the population prefer to be cared for and die at home if they have the choice. However, in the real world, less than one-third of the deaths occur at home.
Home-based care services, as one of the delivery methodologies for palliative care, can potentially address this issue. These locations can provide accommodation, medical/nursing personnel, personal care personnel and food services to these people.
There was a lack of research in this area for many years, but in the last decade there have been many recent studies with published results. Yet there remains the need for well-designed large, randomized multicenter studies in order to recognize the factors that could potentially affect the quality of care for the end-of-life period in these patients.
In a recent study in the United Kingdom, researchers reported around 16,000 nursing homes accommodating around 500,000 people. This population was reported to have a high level of disability and suffered from at least one type of mental impairment. There have been many reports indicating the most common issues in nursing homes, including: falls, urinary incontinence, mental impairment and frailty.
Falls have been reported to be a common problem in nursing homes with an average occurrence of 2-6 times per year for each person at the nursing homes. Of those, one-third has been reported to cause fractures. Different strategies have been proposed to minimize falls, including hip protectors, removal of physical restraints, fall alarm devices, exercise, calcium and vitamin D treatment, changes in the physical environment, and pharmacist medication review.
Urinary and fecal incontinence have been also reported to be highly prevalence in caring homes up to 30-65 and 22-55 percent, respectively. The commonly used treatments for incontinence include regular toileting, pad usage and medication use.
Furthermore, psychiatric disorders, such as anxiety, dementia and depression (40 percent of the population), have been reported to be another common problem in caring homes. Anti-psychotic drugs and anti-depressants are often being prescribed to address these disorders in caring homes.
Finally, frailty has been mentioned to be seen often in caring homes. It has been defined as poor muscle strength and infection vulnerability due to impaired immunity and endocrine system leading to a critically homeostatic capacity reduction in response to any insult. The most effective way to battle frailty is to prevent it through good nutrition and exercise and in case of its occurrence, a multidisciplinary assessment and intervention could help.
It seems that the chance of dying at home could be increased with the introduction of more home-based palliative care for the patients who wish to die at their own home. Furthermore, it can reduce the symptom burden on the patients without affecting the caregiver grief.
Improvements are needed in the area of healthcare professional communication for patients on a home-based palliative care set-up in order to minimize patient suffering and psychological discomforts. Therefore, further detailed studies are needed to address all the unmet needs for this growing portion of population to ensure an acceptable quality of life and a smooth dying process.
These unmet needs could include different models of home palliative care, its cost effectiveness, optimized communication methods, fall prevention measures, symptom burden reduction, pharmacist-led medication reviews and nonpharmacological therapy access.
Furthermore, we need to study the potential reasons for not being able to fully respect the terminal patients' will for dying at the comfort of their homes.
