Background and aims Studies support that the majority of patients want to die at home, yet in London, 66% die in hospital and Nationally, only 35% die in their home/care home. We therefore audited referrals to the hospital palliative care team over a period of 6 months, looking at documentation of and outcomes for preferred place of care/death (PPoC / D). Reasons why preferences were not achieved were documented using a locally adapted version of a model devised by the Health Sciences Research Institute, University of Warwick to measure the constraints to enabling patients to die at their preferred place (Munday et al 2009).

Results 83% of patients had a record of PPoC/D. 79% of patients who expressed a preference achieved this. Unpredictability of illness/rapid deterioration and lack of recognition of the potential for dying, were the main barriers that prevented patients achieving their preferences (41% of patients). For the 17% of patients where there was no record of PPoC/D, 45% was due to cognitive impairment and 31% due to rapid and unexpected deterioration. For patients where rapid and unexpected deterioration was the main factor to not recording/not achieving PPoC/D, discussions had not taken place prior to admission in the acute illness.

Conclusion Better identification of the potential for dying through the use of models such as the Gold Standard Framework in acute hospital's, might reduce barriers to achieving PPoC/D. Conversations about the future and about preferences can be initiated once the potential for dying is recognised. There is also a wider societal need to encourage more open discussion of these difficult issues and thereby address the taboos that surround attitudes towards death and dying to support decision making at the end of life.