Knowing patients' preferences for place of death: how possible or desirable?

In their paper in this issue of the BJGP, Meeussen et al 1 report that GPs knew the preferred place of death for 46% of their patients with non-sudden deaths. This information came from the patient alone for 40%, from significant others alone for 36% and from both for 22%. Patients whose GP knew their preferences were more likely to achieve their wish, and GP knowledge was associated with greater GP involvement in end-of-life care. The authors call for improvement in GPs' knowledge of patients' preferences for place of death, suggesting this to be a marker of end-of-life care quality. The majority of terminally ill patients prefer to die at home; a preference that declines as illness progresses. 2,3 However, such a preference is neither categorical nor fixed, but 'a socially contingent leaning in a particular direction, rather than an abstractly arrived at certainty' qualified by speculation about how things might change with events. 4 A recent paper in the BMJ 5 found preferences for place of death to be often poorly formed in patients' minds, and often inferred by health professionals without direct questioning or reaching a definitive answer. The enabling of patients to achieve their preferred place of death is viewed by the authors as a very limited proxy measure for the effectiveness of palliative care delivery. The NHS End of Life Care Strategy 6 advocates a care pathway that starts with health professionals discussing with patients their care preferences, and advocates the use of the Preferred Priorities for Care document. 7 This is a welcome challenge to health professionals: all of us at times fail to provide adequate opportunities for discussion, or block such conversations when they arise. However, exploring preferences with patients is challenging at several levels. • The GP needs to recognise the probable approach of life's end. This is increasingly difficult in cancer where the dying trajectory 8 has been moderated to one more akin to a chronic disease, due to its therapeutic advances and the increase in continuation of such treatment close to death. Accurate prognostication is very difficult, if not impossible, in the fluctuating dying trajectory of non-malignant illness. It would greatly help if our specialist colleagues either started these discussions with patients themselves, or set the scene for the GP to do so. A GP often lacks the specialist knowledge needed concerning new treatments to inform the conversation. • The patient …