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Telehealth-facilitated palliative care enables more people to die at home: An analysis of clinical outcomes and service activity data

BMC Palliative Care volume 24, Article number: 22 (2025) Cite this article

Abstract

Background

Telehealth-facilitated models of palliative care are a patient-focused way to deliver specialist care in or closer to home for people with a life-limiting illness. Telehealth can increase access to palliative care and support people experiencing symptoms of advanced disease in their own home, reducing the discomfort of travel. This retrospective cohort study examines the activity and outcomes of a regional telehealth-facilitated palliative care service to (i) describe which patients are most likely to use telehealth; and (ii) explore possible impacts of telehealth on patient outcomes including place of death, timely access to care, responsiveness to urgent needs and pain management.

Methods

Analysis of service activity data (patient demographics, care modality, consultation frequency) and Palliative Care Outcomes Collaborative data registry (place of death, timely access to palliative care, responsiveness to urgent needs as measured by time in unstable phase, pain management) were undertaken. Outcomes were compared between patients who had no videoconsultations (n = 683) and those who had one or more videoconsultations (n = 524).

Results

Compared to people who had no videoconsultations, those who had at least one appointment via video were: more than twice as likely to die at home and spent a shorter amount of time in the unstable phase of palliation. Mixed results were found regarding timely access to palliative care. There was no significant difference in pain management between consultation modes.

Conclusion

Telehealth-facilitated palliative care has multiple benefits, including the increased likelihood of fulfilling someone’s wish to die at home, often their preferred place of death.

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Background

Telehealth-facilitated models of palliative care are a patient-focused way to facilitate specialist care in or closer to home for people with a life-limiting illness [1, 2]. Telehealth can enable consultations with the palliative care team without the need for patients and their families to leave their place of residence or travel long distances. The impact of delivering such care cannot be understated for people experiencing symptoms of advanced disease, as it can reduce the discomfort of travel, and sitting in clinical waiting rooms [3]. It can also reduce exposure to infectious diseases that are often in higher levels in clinical environments [4, 5]. As well as improved access to palliative care, telehealth has the potential to: increase monitoring and support; prevent the escalation of symptoms and crises [5], improving patient outcomes; reduce the use of unnecessary clinical services (e.g. emergency departments, hospital admissions) [6] and increase palliative care staff satisfaction [7].

Given constrained palliative care resources and geographical difficulties may inhibit access to care for some people, better use of models of care using newer technologies is needed [8] but are currently underutilised [9, 10].

Recent research provides examples of telehealth-facilitated palliative care that have been rapidly implemented in response to the COVID-19 pandemic and need to control infection [5, 10]. However, ambiguity about the role and effectiveness of telehealth demands a stronger evidence base [11] with many services not undergoing evaluation [12]. A lack of routine application of telehealth, especially within palliative care services [10, 13], means that increased evidence is needed regarding clinical and cost effectiveness and acceptance of such services [11]. Clinician resistance to change and lower rates of acceptance of telehealth [14] create a need to establish evidence regarding the costs and benefits of a telehealth service [7]. While some evidence regarding high levels of patient and caregiver satisfaction [15] and clinical benefits of telehealth in palliative care exist [5, 16], there is still some ambiguity regarding patient outcomes [5, 17] presenting the need for further evaluation of telehealth services.

A central tenet of palliative care philosophy is to empower people’s choices during end-of-life care to enable a “good death.” [16, 18,19,20] For instance, palliative care aims to fulfill people’s wishes regarding where they wish to die. Many people wish to die in or close to home to enhance physical and psychological comfort [18, 19, 21]. Yet, over half of the deaths in Australia occur in a hospital setting [22]. While there is some evidence demonstrating phone support as a way to facilitate preferred place of death [23], further examination of the impact of telehealth (both video and phone) on place of death is needed. Another way to address people’s needs during end-of-life care is through early involvement of a specialist Palliative Care Team. It is well established that numerous psychosocial and clinical benefits are associated with early referral to Palliative Care [24,25,26], which may be enhanced through telehealth [17].

This current study will examine patient outcomes associated with the delivery of a telehealth-facilitated palliative care service. Specifically, this study aims to (i) describe which patients are most likely to use a telehealth-facilitated model of palliative care; and (ii) explore possible impacts of telehealth on patient outcomes including place of death, timely access to care, responsiveness to urgent needs, and pain management.

Methods

Setting

A telehealth service was introduced in February 2016 to support patients requiring end of life care in their own home. The Gold Coast Specialist and Supportive Palliative Care Service is operated as part of a specialist palliative care service in a metropolitan tertiary hospital. The service was established to reduce clinician travel and increase efficiency (time available to deliver patient care). The Gold Coast Specials and Supportive Palliative Care service serves a large 2400 km [2] area that hosts a growing population (around 600,000). There are increasing amounts of people moving into the area from other Australian regions, which results in reduced social support. The traditional model of care meant that consultants travelling to patients’ home were only seeing an average of three patients per day. The telehealth service complements existing in-person care and provides palliative care to people in an urban and regional setting in Gold Coast, Australia. It aims to improve patient outcomes in a range of ways: increasing care to patients in their own home rather than in hospital to alleviate discomfort; increasing the likelihood of people dying in their place of preference (often the home); reducing visits and demand on the emergency department; and increasing timeliness of specialist palliative care provision.

In this service, patients with life limiting illness are assessed and triaged based on need in a holistic manner. That is, some patients are only seen once with others having numerous consultations. General Practitioners and community nurses provide the main support, with the specialist service supplementing where there was added benefit.

Reducing the need for staff to travel to a patient’s home, efficiency gains were realised with a 189% increase in consultations with the same staffing allowance. This meant that the time staff would normally spend commuting to residential settings, could now be spent on increased engagement with patients, online or otherwise [7]. Since its inception, the telehealth service has expanded so that community carers (e.g., from non-government nursing organisations) can use this mode of delivery to consult with palliative specialists, nurses, and allied health professionals.

Data collection

Two data sources representing information from February 2016 to July 2019 were utilised: the [deidentified] Palliative Care Service administrative data and the Palliative Care Outcomes Collaborative (PCOC; [27] dataset. Combining the datasets enabled model of care information to be linked with patient outcomes. The datasets were linked via medical record number and date of birth. This merged data set was de-identified prior to analysis.

Telehealth palliative care service activity data

These data were drawn from the service’s activity data collected via the Enterprise Scheduling Management system. This dataset captures patient demographics and information on the model of care provided (e.g., in-person, telephone, videoconference, age, postcode) and the frequency and number of consultations. Due to different resource constraints depending on geographic region, there are varying eligibility criteria determining access to palliative care across Australia.

PCOC dataset

The PCOC dataset was established in 2005 by the University of Wollongong and funded by the Australian Government Department of Health. Palliative care programs from across Australia routinely upload data into the PCOC registry enabling standardisation of clinical data across services to support national reporting and quality improvement [27]. The PCOC dataset, which captures demographic, setting and clinical assessment information for Palliative Care patients across Australia, provides data regarding patient demographics, phases of palliation and episodes of care [27]. Palliative care Phases refer to five phases of palliation comprised of: stable, unstable, deteriorating, terminal, bereavement/post-death support. An Episode in PCOC is defined as a continuous period of care for a patient in one setting (i.e., hospital, private residence, residential aged care facility etc.). An Episode End involves a transition from one setting to another (e.g., hospital to discharge) or death. Place of death is defined as home, residential age care facility, hospital or unknown [28].

Measures

Primary outcome

Place of death

Place of death was documented as a binary variable: (i) home or (ii) not home (including aged care facility, hospital and unknown).

Secondary outcomes

Timely access to palliative care

defined as the difference between data showing commencement of palliative care and the date the patient was ready for care.

Responsiveness to urgent needs

defined as the time from starting an unstable palliative phase until when it is addressed and patient is either in another phase (predominantly stable or death).

Pain management

captured as a binary variable (phases that ends with no or mild pain level vs. phases that ends with moderate to severe pain level).

Statistical methods

We identified phases from the PCOC dataset that had at least one corresponding matched contact in the hospital service administrative dataset by comparing the phases and contacts identifiers and dates. Then data of phases (from PCOC dataset) and contacts (from service activity dataset) were merged to form the main dataset for this study (See Fig. 1 for data merging procedure). Duplicates which occurred as a result of overlapping data between the two datasets were identified using unique patient identifiers and removed. Further, where unique patient identifiers were present in one dataset but not the other, these were also removed. An overview of the merging process across the two datasets is available in Fig. 1. Descriptive statistics were used to summarise and compare different patient characteristics. Mean (standard deviation; SD) values were used for continuous variables, and frequencies (percentage) for categorical variables. Differences between telehealth and no telehealth were tested using the Student’s t-test (continuous variables) and Pearson’s χ2 (categorical variables) in different levels of data. Logistic regression for binary outcomes (i.e., place of death and pain management) and zero-inflated count models for time-to-event outcomes (i.e., time to access palliative care and time in unstable phase) were fitted to estimate the effect of telehealth. We used a zero-inflated model as there was an excess of zeros [29] in the responsiveness to urgent need and timely access (indicating numerous same day access to service events). In each zero-inflated count model, the zero-inflated part was modelled by a logistic regression and count part was modelled by a Poisson regression. All analyses were performed by R version 4.0.2 and p < 0.05 was considered significant.

Fig. 1
figure 1

Data merging process

Full size image

Results

During a 40-month period from March 2016 – July 2019, retrospective data showed 12,195 unique occasions of service or contacts shown in the hospital service administrative data and 10,827 phases in the PCOC database. Unique patient identification numbers were matched across the two datasets. The total merged dataset consisted of 4751 contacts from 2015 phases clustered in 1544 episodes from 1207 patients. See Fig. 1.

Demographics

Table 1 presents demographic data showing the proportion of different cohorts who did and did not use telehealth. Telehealth was used more with a slightly older cohort (median 75 years vs. 70 years). There were limited differences in the type of cancer and the use of telehealth. There was no significant difference in gender between those who did and did not use telehealth. Of the 1207 patients, all except 5 lived in a metropolitan area (MMM1) as determined by postcode and the Modified Monash Model classification [30].

Table 1 Sociodemographic and clinical characteristics of GCHHS Palliative Care patients as a function of modality of care
Full size table

Main outcomes

Table 2 shows the primary and secondary outcomes, comparing models of care with at least one videoconsultation compared with no videoconsultations. Outcomes of people’s place of death, pain management, timely access to palliative care and time in an unstable phase have been examined as a function of whether or not someone had at least one appointment via videoconsultation.

Place of death

As shown in Table 2, patients with at least one telehealth appointment were more than twice as likely to die at home (OR: 2.37; 95%CI: 1.79–3.15; p < 0.001).

Timely access to palliative care

Same-day commencement (initial palliative care assessment occurring on the same day as the patient is ready to receive care) of the service was 54% less often in those episodes with at least one telehealth contact as compared to those without telehealth contact (OR: 0.46; 95%CI (0.36–0.59); p < 0.001). However, among episodes without same day commencement, patients with at least one telehealth consultation tended to receive their palliative service sooner as compared to phases without telehealth contact (IRR: 0.71 (0.62–0.81); p < 0.001).

Responsiveness to urgent needs

There was no difference in frequency of unstable phases among phases with and without at least one telehealth consultation (OR: 1.35; 95%CI (0.56–3.24); p = 0.503). However, among unstable phases, phases with at least one telehealth consultation tended to end earlier as compared to phases without telehealth contact (IRR: 0.73 (0.56–0.95); p = 0.019).

Pain management

There was no difference in pain management in phases with at least one telehealth consultation and those without telehealth consultation (OR: 0.94; 95%CI: 0.74–1.20; p = 0.623).

Table 2 Potential impact of telehealth on place of death, timely access to palliative care after patient readiness for care, pain management and responsiveness to urgent need (unstable phase)
Full size table

Discussion

Results showed that patients who accessed the telehealth supported palliative care service (had at least one videoconsultation) were significantly more likely to die at home and had a reduced amount of time in an unstable phase where symptoms were not controlled. There was no difference between telehealth and the traditional model of care in terms of the number of unstable phases a patient had and pain management. There were mixed results regarding the impact of telehealth on timely access to care. Demographic results showed which cohorts accessed videoconsultations in the palliative care service. Older patients were more likely to have had videoconsultations compared to a slightly younger cohort.

Increased ability to choose one’s place of death

Results showing that those patients who have at least one videoconsultation were twice as likely to die at home is of utmost importance. This result makes sense, when evidence shows that access to specialist palliative care increases the likelihood of someone dying in their preferred place of death, often the home [31], and videoconsultations are a virtual means of delivering palliative care with greater flexibility, predominantly into the home. There is much research indicating the benefits for people who have their wishes fulfilled regarding where they die and can lead to a “good death” [16, 20, 21]. Indeed, not only is there potentially more peace for the person dying, if they die at home or in their preferred place of death [32] but there can also be positive impacts on the bereaved family. When a person dies in their preferred place of death, it can lessen the intensity of bereavement for family and caregivers [32, 33]. Such positive impacts cannot be understated as bereaved family share death stories of loved ones over the years, as part of a health grieving process [34].

Timely access to care

The results regarding timely access to palliative care were mixed. In-person care resulted in more ‘same-day’ consultations - as in an initial palliative care assessment occurred on the same day as the referral to the Gold Coast Specialist and Supportive Palliative Care team. However, if the patients did not receive an initial palliative care assessment on the same day as their referral to the service, telehealth resulted in faster access to care. The modality of each appointment (e.g., home visit, videoconsultation, clinic-based) is determined on a case-by-case basis and takes into consideration factors such as the clinical urgency, clinician availability, travel distance and the requirements of other personnel to be present at the appointment (e.g., community nurses and family members). Our data reflects this complexity. Same-day care was more likely to be provided in-person. However, for the cohort that were unable to receive same-day care (potentially those who lived further from the facility, were less urgent, or required additional scheduling complexities) telehealth resulted in more timely access.

Evidence is mixed with regard to the impact of referral to Palliative Care and inpatient admissions. Supporting our results above, Scibetta and colleagues [35] found that the earlier a person was referred to Palliative Care the lower rates of inpatient and emergency department use occurred in the last month of life. However, contrary to our findings, other research indicates that earlier referral to the palliative care service meant earlier admission to the hospice, but less aggressive end-of-life care [36]. Overall, however, the importance of early referral to palliative care for quality of life and optimal care is evident across a range of illnesses [37, 38].

Responsiveness to urgent need

As discussed in the results section, responsiveness to urgent need was assessed by examining the number of unstable phases patients experienced, and the length of time in those unstable phases. There was no difference between the two models of care (telehealth and in person care) in relation to time in terms of how many unstable phases occurred. Yet, patients who had used telehealth spent less time in an unstable phase compared with those who did not access videoconsultations. This reduction in time spent in the unstable phase aligns with Benchmark 2 (time patient spent in an unstable phase) of the Australian Palliative Care outcomes and benchmarks program, which helps services develop and compare their outcomes nationally [39].

Pain management

Given that there was no difference in pain management between the two models of care, the results also demonstrated that telehealth was no less effective than in person models of care in treating pain in palliative patients. Although it can be context-dependent there is strong evidence across medical specialties that videoconsultations can be as effective as in person consultations and bring varying benefits [5]. Evidence shows a perception that videoconsultations offers advantages over telephone consultations, leading to the delivery of higher quality care [40, 41].

Limitations

This study is based on PCOC data and therefore reliant on the quality of the data. PCOC data is input by a range of clinicians and some decision-making regarding which phase a patient is in, has a level of subjectivity [42]. This issue, especially when determining the unstable phase, has been raised previously, but considering the clinicians inputting the current data are all Palliative Care trained, less error is expected [42].

Further, we did not have data indicating preferred place of death or whether patients lived alone. As such, we drew upon evidence that suggests most palliated individuals wish to die in their own homes [16, 43], with some estimates as high as 70% of people preferring to die at home [19]. However, we also acknowledge that someone’s preferred place of death is what they regard as their ‘safe place’, which may not necessarily be home [18].

We also acknowledge that there may be confounding variables that influence the outcomes such as proximity to death or intentions regarding place of death which were not accounted for in our analysis.

Future directions

Although this research aligns with evidence showing the benefits of care closer to home, it is important to consider the quality of care at home. Our research indicated that theGold Coast Specialist and Supportive Palliative Care Telehealth Service was not inferior regarding pain management, but further research is needed using the PCOC Symptom Assessment Scale, to ensure that all symptoms are being managed effectively in the home. Regardless, the main outcomes of this research indicates the benefits that can be gained across other palliative care services wherein a hybrid model of care (telehealth and in-person) can provide increased quality and patient-centred care.

Conclusion

This study showed that people, regardless of a range of demographic characteristics, can access palliative care through the use of telehealth. Of importance, bringing palliative care into the home by videoconsultation can more than double the likelihood of someone dying at home, often the preferred place to die, and reduce the length of time the patient is in the unstable palliative care phase. However, there were mixed results regarding the possible impact of telehealth on the timeliness of care access, which need further investigation. Pain management via videoconference was not inferior to in-person. The impact of increasing access to palliative care within one’s home, through telehealth has multiple benefits. This research highlights a major benefit of telehealth in increasing the likelihood of fulfilling someone’s preference to die at home, should they wish to do so.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to patient confidentiality and human research ethics agreements, but are available from the corresponding author on reasonable request.

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Acknowledgements

Thank you to the staff at the University of Wollongong, Australia, for their advice during the analysis of the Palliative Care Outcomes Collaboration data.

Funding

Supportive and Specialist Palliative Care; Gold Coast Health, Queensland Health provided funding for an evaluation of the telehealth supported palliative care service.

Author information

Authors and Affiliations

  1. Centre for Online Health, The University of Queensland, Brisbane, Australia

    Helen M. Haydon, Mojtaba Lotfaliany, Centaine L. Snoswell, Anthony C Smith, Liam J. Caffery & Emma E. Thomas

  2. Centre for Health Services Research, The University of Queensland, Brisbane, Australia

    Helen M. Haydon, Mojtaba Lotfaliany, Centaine L. Snoswell, Anthony C Smith, Liam J. Caffery & Emma E. Thomas

  3. Gold Coast Specialist and Supportive Palliative Care service, Gold Coast Hospital, Robina, Australia

    Andrew Broadbent & Julie-Ann Brydon

  4. Centre for Innovative Medical Technology, University of Southern Denmark, Odense, Denmark

    Anthony C Smith

  5. Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Deakin University, Geelong, Australia

    Mojtaba Lotfaliany

Authors
  1. Helen M. Haydon
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  2. Mojtaba Lotfaliany
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  3. Andrew Broadbent
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  4. Centaine L. Snoswell
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  7. Liam J. Caffery
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  8. Emma E. Thomas
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Contributions

HH was the research lead and oversaw the project. ML designed and completed the statistical analysis, with additional statistical advice provided by CS and data analysis support from ET. AB was the clinical lead and helped coordinate the project and give advice on data matters. JB was responsible for data collection and transfer from the clinical service to the university staff. AS and LC provided research methods advice and LC, HH, and ET wrote the main manuscript text. All authors contributed in part to writing and editing the manuscript, and all authors read and approved the final manuscript.

Corresponding author

Correspondence to Helen M. Haydon.

Ethics declarations

Ethics approval and consent to participate

Ethics approval to use this service activity and patient data was provided by the Gold Coast Hospital and Health Service Human Research Ethics Committee (HREC/2019/QGC/51879) and additionally ratified by The University of Queensland Human Research Ethics Committee (Clearance Number: 2019002355). The Gold Coast Hospital and Health Service Human Research Ethics Committee waived the need for informed consent to be obtained as the data was de-identified and an application for data release under the Public Health Act 2005 (PHA) was approved by data custodians and the office of the Director General of Queensland Health.

Consent for publication

Not applicable.

Competing interests

Although the evaluation that led to this manuscript was carried out independently through The University of Queensland research team members, authors AB and JB are employees of the palliative care service.

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Haydon, H.M., Lotfaliany, M., Broadbent, A. et al. Telehealth-facilitated palliative care enables more people to die at home: An analysis of clinical outcomes and service activity data. BMC Palliat Care 24, 22 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12904-024-01622-0

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12904-024-01622-0

Keywords

BMC Palliative Care

ISSN: 1472-684X

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