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

Abstract

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 utilization 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. EXPOSURES 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 18,452 decedents who underwent maintenance dialysis were included (median age=71 years; 61.1% male). 52.2% received physician-delivered palliative care in the last year of life starting a median of 23 days before death. 65% died in 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 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.