Due to the COVID-19 pandemic, the UK has experienced the highest rate of death in many years. At the same time, there has been a marked change in the place of death, with a 67% increase in deaths at home during the first wave of the pandemic; this was sustained at lower levels during the second and third waves (O'Donnell et al, 2021). The circumstances of these home deaths and the quality of the end-of-life care offered has not been reported, but it is well documented that many primary care consultations became remote rather than face-to-face during the pandemic. This change reflected those occurring in many areas of clinical practice and care delivery, both to minimise infection risk and to maximise limited resources.
Prior to the pandemic, much palliative and end-of-life care was oriented towards supporting people with cancer rather than non-malignant conditions and frailty, despite the growing needs of those with complex multi-morbidities and frailty who are living longer (Polak et al, 2020). The National Institute of Health and Care Excellence (NICE) (2019) guideline provides service and practice recommendations for all those approaching the end of their lives; this is augmented by another earlier guideline (NICE, 2015) which focuses upon best practice provision during the last few days of life, including access to appropriate symptom control through anticipatory prescribing. Bowers et al (2021) have described the challenges of providing end-of-life care during the pandemic, many of which district nurses overcame through their innate flexibility and creativity, to ensure that their clients' needs were given primacy. They also identified opportunities for new ways of working and for nursing roles in the community within end-of-life care, which may become embedded post-pandemic when services have a chance to regroup and reflect upon what worked well and what changes are needed to further enhance the delivery of high-quality care.
The first lockdown was not only associated with a significant increase in deaths at home, but also a significant rise in markedly decomposed bodies having coronial autopsies in a central London mortuary (Estrin-Serlui and Osborn, 2021). Researchers noted that every case of a markedly decomposed home death was someone who had lived alone, and they speculated that the public health measures designed to minimise the spread of SARS-CoV-2 within the community increased social isolation, with the frequency of advanced decomposition being a proxy measure of social isolation (Estrin-Serlui and Osborn, 2021). Thus, a death at home may be missed until a chance discovery due to the smell of decomposition or other evidence, such as unexplained long-term absence or non-collection of deliveries. That anyone dies unnoticed in the UK is profoundly sad, and indicates the urgent need to address the social isolation of those living alone in the absence of daily deliveries and the loss of close-knit communities where neighbours are in daily contact. It is to be hoped that ‘building back better’ following the pandemic will include strategies to reduce social isolation, especially among the vulnerable and those at the end of their lives.
‘It is to be hoped that “building back better” following the pandemic will include strategies to reduce social isolation, especially among the vulnerable and those at the end of their lives.’