“Place of death and late referral in home palliative care: the impact of caregivers and social care-related factors”

Over recent decades, demographic and social transformations, together with the increasing demand for palliative care, have progressively reshaped end-of-life care pathways. However, the role of social care-related factors in influencing care trajectories remains insufficiently explored. This study aimed to assess the association between social care-related variables, place of death, and timing of referral in home palliative care. In this retrospective cohort study, we included adult patients who died after enrollment in a public home-based palliative care service in Italy between 2019 and 2025. Patients aged < 18 years or with missing data on place of death were excluded. Data were extracted from electronic medical records and included demographic and social care-related variables. The primary outcomes were place of death (home vs. hospice) and late referral, defined as a formal request to initiate home palliative care made ≤ 14 days before death. Univariate and multivariable logistic regression analyses were performed. A total of 3143 patients were included (median age 80 years); 71.0% died at home and 45.6% had late referral. Non-oncological diagnosis was associated with a lower likelihood of hospice death (OR 0.55; p < 0.001) and a higher likelihood of late referral (OR 1.76; p < 0.001). Among social care-related variables, caregiver frailty (OR 1.61; p < 0.001) and high family relationship complexity (OR 1.58; p = 0.001) were associated with increased odds of hospice death. Late referral was significantly associated with caregiver frailty (OR 1.24; p = 0.028), decision-making difficulties (OR 1.37; p = 0.004), and the presence of a non-family caregiver (OR 1.26; p = 0.013). Temporal trend analyses showed a significant increase in hospice deaths over time (p-trend = 0.003) and significant increases in several social care-related variables, whereas no significant trend was observed for late referral. Social care-related factors, particularly those involving caregiver vulnerability and relational dynamics, were significantly associated with both place of death and timing of referral in home palliative care. These findings highlight evolving care needs and support the importance of early, multidimensional assessment integrating social and family domains.