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When it comes to death, there is no place like home… Or is there?

The primary focus of palliative care is to maximize patients’ quality of life, reduce symptoms, and help patients make decisions that honor their values and preferences (related to treatments, end-of-life preferences for location of death, etc.). Since the landmark SUPPORT study,1 overwhelming evidence suggests that use of emergency and acute care services near death often does not meet these goals as patients and families experience distress and suffering as a result of patients receiving overly aggressive, burdensome treatments and oftentimes being tethered to machines. From this perspective, there would seem to be no place like home. This is an underlying theme in this issue’s studies by Reyniers et al.2 and Sutradhar et al.3 that examine how palliative care involvement is contributing to reduced use of acute care services by seriously ill and dying patients and their surviving family members. Reyniers and colleagues examined family physicians’ perspectives on the appropriateness and avoidability of their patients’ hospitalized death. The overall number of deaths in these categories was relatively low; only 14% were considered inappropriate, an equal number were considered avoidable, and 8% were considered both inappropriate and avoidable. Three characteristics were associated with inappropriate/avoidable deaths: poorprognosis cancers, admission initiated by their family member, and a family physician with additional palliative care training. Reyniers et al.’s findings shine a light on why avoidable, inappropriate deaths in hospital occur. One reason is lack of or late communication about prognosis and inadequate advance care planning—an issue routinely addressed by early palliative care. Persons with poor-prognosis cancers and potentially curable hematological malignancies,4 who have been exposed to early palliative care, experience earlier conversations, better quality of life, mood, reduced symptoms, and fewer in hospital deaths than those who had usual cancer care.5,6 However, even though studies have documented the benefits of early palliative care, this care model has yet to be widely adopted.7 Reyniers et al.’s findings also raise a number of important questions. First, we do not know whether family physicians were aware of patients’ wishes about where they wished to die and whether they considered the patients’ wishes when making a judgement about the appropriateness decision. Second, the investigators did not ask family physicians to rate the admissions’ avoidability and appropriateness of patients who died in the palliative care unit. This may be a missed opportunity since there has been limited attention to the desirability and acceptability of the palliative care unit as the location of hospital death when home death is not possible. Should we assume palliative care unit deaths are always appropriate and never avoidable? Documenting whether and how hospital death in a palliative care unit is consistent with patients’ wishes may help support the value of such services. While there is strong evidence about the impact of palliative care on hospitalization,5 Sutradhar and colleagues extend this knowledge by examining the impact of specialized palliative home care (compared to general home care) on highand low-acuity emergency department (ED) visits, hypothesizing that palliative home care might not be able to reduce the risk of ED visits due to high-acuity problems such as sepsis or respiratory distress. Strikingly, the investigators found that both lowand high-acuity visits were statistically lower in patients receiving specialized palliative home care. How could this be? How does specialized palliative home care reduce ED visits due to more complex issues? Sarmento et al.’s8 recent meta-ethnography of 19 qualitative studies of palliative home care summarized patient and family perspectives on “what works.” Families described how home palliative care provided a sense of security through presence (24 h per day/7 day per week availability) and competence (expertise in symptom control and communication) suggesting that symptom management and less panic by families seemed to be specialized home care’s operative elements. The studies discussed here have added to the corpus of evidence demonstrating the value of palliative care; however, they also reveal on-going challenges and priority areas for discovery and dissemination. Two questions readily come to mind: How can we support family caregivers who can have a major influence on patients’ acute care 703861 PMJ0010.1177/0269216317703861Palliative MedicineEditorial research-article2017