Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer

Abstract

Importance: Palliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking.

Objective: To examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer.

Design, setting, and participants: This population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada.

Exposures: Cause of death (chronic organ failure, dementia, or cancer).

Main outcomes and measures: Components of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death.

Results: A total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, -18.3%) or dementia (3922 [27.9%]; absolute difference, -13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%).

Conclusions and relevance: In this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings.

Figure 1.. Flow Diagram for the Creation of the Study Sample

All adults who died of heart failure (HF), chronic obstructive pulmonary disease (COPD), end-stage kidney disease (ESKD), stroke, dementia, or cancer were assessed for inclusion in the study. Patients who received their first consultation with palliative care within the last year of life at least 7 days before death were included. OHIP indicates Ontario Health Insurance Plan.

Figure 2.. Location of Death Among Patients Receiving Palliative Care in the Last Year of Life in Ontario Between 2010 and 2017 According to Illness Type and Timing of Palliative Care Initiation