BMJ Support Palliat Care 3:144-154 doi:10.1136/bmjspcare-2012-000292
  • Review

Congruence between preferred and actual place of death according to the presence of malignant or non-malignant disease: a systematic review and meta-analysis

Editor's Choice
  1. Sarah-Jane Billingham3
  1. 1Department of Medicine, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Telford, Shropshire, UK
  2. 2Department of Palliative Medicine, Douglas Macmillan Hospice, Stoke-on-Trent, Staffordshire, UK
  3. 3Department of Anaesthetics, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
  1. Correspondence to Dr Matthew James Billingham, Department of Medicine, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Telford, TF1 6TF, UK; mbillingham{at}


Objectives Achieving congruence between preferred and actual place of death is increasingly being used as a quantifiable indicator of the effectiveness of palliative care services. Current secular trends indicate a reversal of the institutionalisation of death, but this has been more pronounced in patients with malignant disease. As such, this study was conducted to evaluate whether the preservation of autonomy has been addressed equitably for cancer and non-cancer populations.

Methods A systematic review and meta-analysis was performed in line with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive computerised search of 14 databases, supplemented by a manual review of the literature was performed for all peer-reviewed publications, from 1980 to the present, identifying rates of incongruence for cancer and/or non-cancer cohorts. Aggregation of outcomes was performed using a random effects model.

Results A total of 26 articles were identified that met the search and inclusion criteria. A non-cancer diagnosis was found to significantly increase the incidence of incongruence with a weighted risk ratio of 1.23 (95% CI 1.01 to 1.49, p=0.04) and this disparity appears to have increased since 2004. A moderate degree of heterogeneity was noted (I2=62%).

Conclusions These findings pose a significant challenge, as a ‘good’ death has been closely matched to achieving patients’ wishes, including preferred place of death. Despite increasing awareness that those dying from chronic non-malignant diseases have extensive palliative care needs, much is still to be done to preserve their autonomy and reduce powerlessness in the face of death.

  • Received 28 May 2012.
  • Revision received 17 November 2012.
  • Accepted 20 November 2012.
  • Published Online First 22 January 2013

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