Health Quality Ontario

Home and Community Care

End of Life

Best Practices

Created on October 03, 2017

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

End of Life, Preferred Place of Death is a priority indicator for the QIP. This indicator measures the percentage of palliative/end of life patients who died in their preferred place of death. To access your organization's data for the reporting period, refer to Health Quality Ontario’s QIP Navigator.

Below are best practices and change ideas for improving on the end of life preferred place of death indicator in home care. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice refer to Health Quality Ontario’s relevant reports

Or browse the interactive table below for a quick summary of how to improve home care patients’ end of life and facilitate dying in their preferred location.

  1. Bainbridge D; Seow H; Sussman J.(2016).
    Common Components of Efficacious In-Home End-of-Life Care Programs: A Review of Systematic Reviews.
    [Review]. Journal of the American Geriatrics Society. 64(3):632-639.

  2. Bainbridge D; Seow H; Sussman J; Pond G; Barbera L.(2015).
    Factors associated with not receiving homecare, end-of-life homecare, or early homecare referral among cancer decedents: A population-based cohort study.
    Health Policy. 119(6):831-839.

  3. Burge F; Lawson B; Johnston G; Asada Y; McIntyre PF; Flowerdew G.(2015).
    Preferred and Actual Location of Death: What Factors Enable a Preferred Home Death?.
    Journal of Palliative Medicine. 18(12):1054-1059.

  4. Costa V.
    The determinants of place of death: an evidence-based analysis.
    Ont Health Technol Assess Ser. 2014 December;14(16):1–78.
    Available from:

  5. de Graaf E; Zweers D; Valkenburg ACh; Uyttewaal A; Teunissen SC.(2016).
    Hospice assist at home: does the integration of hospice care in primary healthcare support patients to die in their preferred location - A retrospective cross-sectional evaluation study.
    Palliative Medicine. 30(6):580-586.

  6. Dillon EC.(2016).
    How home hospice care facilitates patient and family engagement.
    Death Studies. 40(10):591-600.

  7. Gagnon B; Nadeau L; Scott S; Dumont S; MacDonald N; Aubin M; Mayo N.(2015).
    The Association Between Home Palliative Care Services and Quality of End-of-Life Care Indicators in the Province of Quebec.
    Journal of Pain & Symptom Management. 50(1):48-58.

  8. Gomes B; Calanzani N; Koffman J; Higginson IJ. (2015).
    Is dying in hospital better than home in incurable cancer and what factors influence this?
    A population-based study. BMC Medicine. 13:235.

  9. Guerriere D; Husain A; Marshall D; Zagorski B; Seow H; Brazil K; Kennedy J; McLernon R; Burns S; Coyte PC.(2015).
    Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada.
    Journal of Palliative Care. 31(2): 76 - 88.

  10. Hamano J; Yamaguchi T; Maeda I; Suga A; Hisanaga T; Ishihara T; Iwashita T; Kaneishi K; Kawagoe S; Kuriyama T; Maeda T; Mori I; Nakajima N; Nishi T; Sakurai H; Shimoyama S; Shinjo T; Shirayama H; Yamada T; Morita T.(2016).
    Multicenter cohort study on the survival time of cancer patients dying at home or in a hospital: Does place matter?.
    Cancer. 122(9):1453-1460.

  11. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD.
    2012 Audit and feedback: effects on professional practice and healthcare outcomes.
    Cochrane Database of Systematic Reviews 10.1002/14651858.CD000259.

  12. Kondo S; Shimazu T; Morizane C; Hosoi H; Okusaka T; Ueno H.(2014).
    A retrospective analysis of factors associated with selection of end-of-life care and actual place of death for patients with cancer.
    BMJ Open. 4(5):e004352.

  13. Leff B; Carlson CM; Saliba D; Ritchie C. (2015).
    The invisible homebound: setting quality-of-care standards for home-based primary and palliative care.
    Health Affairs. 34(1):21-29.

  14. McCusker M, Ceronsky L, Crone C, Epstein H, Greene B, Halvorson J, et al.
    Palliative care for adults.
    Bloomington (MN): Institute for Clinical Systems Improvement;2013.
    Retrieved from: https://http/

  15. Melin-Johansson C; Axelsson B; Gaston-Johansson F; Danielson E.(2010).
    Significant improvement in quality of life of patients with incurable cancer after designation to a palliative homecare team.
    European Journal of Cancer Care. 19(2):243-250.

  16. National Institute for Health and Care Excellence.
    Care of dying adults in the last days of life.
    London (UK): National Clinical Guideline Centre; 2015.
    Retrieved from: https://

  17. Noble B; King N; Woolmore A; Hughes P; Winslow M; Melvin J; Brooks J; Bravington A; Ingleton C; Bath PA. (2015).
    Can comprehensive specialised end-of-life care be provided at home?
    Lessons from a study of an innovative consultant-led community service in the UK.
    European Journal of Cancer Care. 24(2):253-266.

  18. Pouliot K; Weisse CS; Pratt DS; DiSorbo P.(2017).
    First-Year Analysis of a New, Home-Based Palliative Care Program Offered Jointly by a Community Hospital and Local Visiting Nurse Service.
    American Journal of Hospice & Palliative Medicine. 34(2):166-172.

  19. Prioleau PG; Soones TN; Ornstein K; Zhang M; Smith CB; Wajnberg A.(2016).
    Predictors of Place of Death of Individuals in a Home-Based Primary and Palliative Care Program.
    Journal of the American Geriatrics Society. 64(11):2317-2321.

  20. Registered Nurses' Association of Ontario.
    End-of-life during the last days and hours.
    Toronto (ON): Registered Nurses' Association of Ontario; 2011.
    Retrieved from:

  21. Reich O; Signorell A; Busato A. (2013).
    Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data.
    BMC Health Services Research. 13:116.

  22. Seow H., Bainbridge D., Brouwers M., Pond G., Cairney J. (2017).
    Validation of a modified VOICES survey to measure end-of-life care quality: the CaregiverVoice survey.
    BMC Palliative Care. 16(44): 1-8.

  23. Seow H; Dhaliwal G; Fassbender K; Rangrej J; Brazil K; Fainsinger R. (2016).
    The Effect of Community-Based Specialist Palliative Care Teams on Place of Care.
    Journal of Palliative Medicine. 19(1):16-21.

  24. Seow H; Sutradhar R; McGrail K; Fassbender K; Pataky R; Lawson B; Sussman J; Burge F; Barbera L.(2016).
    End-of-Life Cancer Care: Temporal Association between Homecare Nursing and Hospitalizations.
    Journal of Palliative Medicine. 19(3):263-270.

  25. Seow Hsien, Bainbridge Daryl, Bryant Deanna, Guthrie Dawn, Urowitz Sara, Zwicker Victoria, and Marshall Denise. (2016).
    The CaregiverVoice Survey: A Pilot Study Surveying Bereaved Caregivers To Measure the Caregiver and Patient Experience at End of Life.
    Journal of Palliative Medicine. 19(7): 712-719.

  26. Shepperd S; Goncalves-Bradley DC; Straus SE; Wee B.(2016).
    Hospital at home: home-based end-of-life care.
    [Review][Update of Cochrane Database Syst Rev. 2011;(7):CD009231; PMID: 21735440].
    Cochrane Database of Systematic Reviews. 2:CD009231, 2016 Feb 18.

  27. Sneesby L. (2015).
    Home is where I want to die: Kelly's journey [Case Study].
    Contemporary Nurse. 46(2):251-253.

  28. Tan WS; Lee A; Yang SY; Chan S; Wu HY; Ng CW; Heng BH.(2016).
    Integrating palliative care across settings: A retrospective cohort study of a hospice home care programme for cancer patients.
    Palliative Medicine. 30(7):634-641.

  29. Tan YY; Xu ZZ; Pang GS; Qu L; Xu Y; Zhang AM; Neo PS.(2016).
    Facilitating terminal discharge: fulfilling the hospitalised patient's wish for home death in the final hours.
    International Journal of Palliative Nursing. 22(11):541-548.

  30. Topf L; Robinson CA; Bottorff JL.(2013).
    When a desired home death does not occur: the consequences of broken promises.
    Journal of Palliative Medicine. 16(8):875-880.

  31. Yu M; Guerriere DN; Coyte PC.(2015).
    Societal costs of home and hospital end-of-life care for palliative care patients in Ontario, Canada.
    Health & Social Care in the Community. 23(6):605-618.


Created on October 03, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another

Indicator End of Life, Preferred Place of Death
Topic End of Life, Palliative
Quality Dimension Patient – Centred
Type of Indicator Outcome
Measure Percentage (%)
Data Source Client Health and Related Information System (CHRIS)
Data Collection Instrument Collected by Health Shared Services Ontario (formerly the Ontario Association of Community Care Access Centres (OACCAC))
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of palliative / end of life patients who died in their preferred place of death. Patient must be discharged with a disposition of death in the period selected.

Denominator: # of palliative/ end of life patients whose discharge disposition is death in the reporting period.

Target Higher is better
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Tools & Resources

Created on October 03, 2017

Health Quality Ontario’s Tools and Resources
Other Tools and Resources


Created on October 03, 2017


When surveyed, the majority of people in Ontario say they would prefer to die at home rather than in hospital (Brazil et al., 2005). However, the reality of a home death may not be easy to achieve. In some cases, medical interventions and procedures may be better performed in hospital, or the home death might be more challenging than originally thought (Costa 2014; Stenekes 2015; Hospice Palliative Care Association, 2012).

Where a person dies depends on an interplay of various factors known as the “determinants of place of death” (Costa, 2014). Determinants that increase the likelihood of dying at home include:

  • multidisciplinary palliative care provided in the patient’s home
  • early referral to palliative care
  • fewer / no hospitalizations during the end-of-life period
  • living with someone (i.e. presence of an informal caregiver)
  • patients’ and family members’ preference for a home death
  • the patient’s disease.

More than 54,000 people in Ontario received palliative care services between April 2014 and the end of March 2015. Of these patients about half (47.9%) began receiving palliative care in their last month of life. Of these people approximately two-thirds (64.9%) died in hospital and nearly two-thirds (62.7%) had unplanned emergency department visits in their last month of life (HQO, 2016). Less than half (43.3%) received palliative home care services with approximately one-third (34.4%) receiving a home visit from a doctor in their last month of life (HQO, 2016).

Call to Action

We know patients should receive palliative care much earlier than they often do, with a multidisciplinary team in the home. These factors increase the patient’s ability to die in their preferred place. In the past, the approach to palliative care was that it wouldn’t begin until the very latest stages of the illness or often not at all. The newer approach to palliative care is that it can begin immediately after the patient is diagnosed with a life-threatening condition. Efforts to improve palliative care delivery will require engaging with the public, with clinicians and teaching people to understand the role of palliative care which should be offered alongside care that is intended to prolong survival throughout the entire course of treatment.

  1. Brazil K, Howell D, Bedard M, Krueger P, Heidebrecht C. (2005).
    Preferences for place of care and place of death among informal caregivers of the terminally ill.
    Palliative Medicine. 19(6):492-9.

  2. Costa V.
    The determinants of place of death: an evidence-based analysis.
    Ont Health Technol Assess Ser. 2014 December;14(16):1–78.
    Available from:

  3. Health Quality Ontario.
    Palliative Care at the End of Life.
    Queens Printer for Ontario, 2016. Toronto ON.
    Retrieved from:

  4. Hospice Palliative Care Association.
    Cost-effectiveness of palliative care: A review of the literature.
    The Way Forward Initiative: an Integrated Palliative Approach to Care; 2012.
    Retrieved from:

  5. Stenekes S, Streeter L.
    Considerations for a home death.
    Winnipeg (MB): Canadian Virtual Hospice; Copyright 2003-2015.
    Retrieved from: