title: Death at home following a targeted advance-care planning process at home: the kitchen table discussion.
abstract: OBJECTIVE
  To determine whether home health agency patients' preferences to die at home can be honored following a structured, professionally facilitated advance-care planning (ACP) process provided in the home.
  
  
  METHODS
  A case series of patients who were identified by their home health agency nurses as having a life-limiting illness and then referred for social service assessment, followed for at least 6 months, with median follow-up of 191 days.
  
  
  METHODS
  A large, urban, home health agency owned by a not-for-profit integrated healthcare system.
  
  
  METHODS
  Eighty-four adult patients (median age 75, range 37-94) receiving home care services other than hospice.
  
  
  METHODS
  Formally structured social work visits at patients' homes to discuss end-of-life issues, with communication of results to home health nurses and attending physicians. Social workers performed standard psychosocial assessments, obtained patient and family preferences regarding end-of-life care, and provided education about hospice services.
  
  
  METHODS
  Acceptance of the ACP process, preferences for location of end-of-life care, location of care at the end of life, adequacy of timing of intervention as measured by length of life after ACP, and use of hospice services.
  
  
  RESULTS
  Eighty-three of 84 participants (99%) were willing to complete an ACP process in the home setting. Of the 54 patients expressing a clear preference for location of end-of-life care, 46 (82%) wanted this care to be at home. Thirty-nine (46%) of the participants died within 90 days of ACP; 58 (69%) died by the end of the study. Forty-three (75%) of these deaths occurred at home or in a hospice residence. Fifty-one (61%) patients used home, residential, or nursing home-based hospice services during the study.
  
  
  CONCLUSIONS
  In this series of seriously ill home health patients, most preferred to die at home and virtually all were willing to participate in a home-based ACP process. Facilitating ACP among such patients and their families was associated with end-of-life care at home. Use of hospice services was common following ACP in this population.
authors.affiliation: University of Minnesota, Department of Family Practice, Minneapolis, Minnesota 55414, USA.
authors.forename: E
authors.initials: E
authors.lastname: Ratner
authors.forename: L
authors.initials: L
authors.lastname: Norlander
authors.forename: K
authors.initials: K
authors.lastname: McSteen
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D005190:Family / Q000523:psychology; D005260:Female; D005500:Follow-Up Studies; D006302:Health Services Research; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D020380:Needs Assessment / Q000458:organization & administration; D010043:Outcome and Process Assessment, Health Care; D010347:Patient Care Planning / Q000458:organization & administration*; D010353:Patient Education as Topic / Q000458:organization & administration*; D010358:Patient Participation; D015397:Program Evaluation; D012017:Referral and Consultation / Q000458:organization & administration; D012947:Social Work / Q000458:organization & administration*; D013727:Terminal Care / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration