Delivery of Palliative Care in the Last Year of Life to Individuals Receiving Maintenance Dialysis: A Population-Level Cross-Sectional Study.

RATIONALE &

OBJECTIVE

Little is known about physician-delivered palliative care and the sociodemographic and clinical factors associated with its utilization for individuals undergoing maintenance dialysis. This study described physician-delivered palliative care in the last year of life and evaluated the factors associated with its use in this patient population.

STUDY

DESIGN

Population-level cross-sectional study.

SETTING &

PARTICIPANTS

Individuals undergoing maintenance dialysis who died between April 2012 and March 2020 in Ontario, Canada.

EXPOSURE: Sociodemographic factors (age, sex, immigration status, neighborhood-level income quintile, rurality, health region), comorbidities (heart failure, cirrhosis, pulmonary disease, dementia, malignancy), and kidney-specific factors (dialysis modality, access, duration; and prior kidney transplantation).

OUTCOME: Physician-delivered palliative care.

ANALYTICAL APPROACH: Descriptive statistics characterizing physician-delivered palliative care. Logistic regression evaluating the factors associated with utilization.

RESULTS

The study included 18,452 decedents who underwent maintenance dialysis (median age, 71 years; 61.1% male). Of these decedents, 52.2% received physician-delivered palliative care in the last year of life starting a median of 23 days before death; 65% died in the hospital, and 12% at home. Palliative care was initiated by a family physician for 68% of those receiving physician-delivered palliative care. It was delivered in the clinic setting for 44.8% and through a generalist-only model for 46%. The odds of receiving palliative care were higher in the setting of a malignancy, dementia, or cirrhosis and were lower among those who were recent immigrants, lived in lower-income neighborhoods, and resided in less dense/more rural regions. The odds of dying in a hospital were lower among those who received palliative care, especially if it was delivered at home.

LIMITATIONS: Exclusion of palliative care provided by non-physician providers and inability to infer causal associations or to comment on the goal-concordance of end-of-life care.

CONCLUSIONS

Over half of decedents who underwent maintenance dialysis received physician-delivered palliative care in the last year of life, albeit typically starting 3 weeks before death. This may indicate a perception that palliative care is exclusively for end-of-life care. More research is required to identify barriers to delivering equitable palliative care.

PLAIN-LANGUAGE SUMMARY: There is limited information about doctor-provided palliative care and the factors associated with receiving this care in people on maintenance dialysis. Among 18,452 people on dialysis who died in Ontario between 2012 and 2020, we found that 52% received palliative care in the last year of life starting a median of 23 days before death. Care was typically provided by family doctors in clinics without participation by palliative care specialists. Patients who were recent immigrants, who lived in low-income neighborhoods, or who lived in rural areas were less likely to receive palliative care. Hospital deaths were less common in people who received palliative care, especially if it was provided in the home. These findings highlight the need to better understand barriers to receiving timely and equitable palliative care for people on dialysis.