Palliative care may reduce healthcare use, burdensome interventions in terminally ill patients

Palliative care provides potential benefits in some terminal noncancer illnesses, as seen in the reduced rates of healthcare use and increased likelihood of a home death from chronic organ failure, but not dementia, suggests a study.

“Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have major implications for health policy,” the researchers said.

This population-based matched cohort study was conducted between 2010 and 2015 in Ontario, Canada, and included a total of 113,540 adults dying from cancer and noncancer illness who received newly initiated physician-delivered palliative care in the last 6 months of life administered across all healthcare settings.

The researchers used linked health administrative data to match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organize all healthcare services in Ontario), and a propensity score to receive palliative care, which was derived by using age and sex.

Among patients dying from noncancer illness related to chronic organ failure (eg, heart failure, cirrhosis, and stroke), those who received palliative care had reduced rates of emergency department (ED) visits (crude rate [CR], 1.9 vs 2.9 per person-year; adjusted rate ratio [aRR], 0.88, 95 percent confidence interval [CI], 0.85–0.91), admissions to hospital (CR, 6.1 vs 8.7 per person-year; aRR, 0.88, 95 percent CI, 0.86–0.91), and admission to the intensive care unit (CR, 1.4 vs 2.9 per person-year; aRR, 0.59, 95 percent CI, 0.56–0.62) compared to patients who did not receive such care. [BMJ 2020;370:m2257]

Palliative care also increased the likelihood of dying at home or in a nursing home compared with dying in hospital (49.5 percent vs 39.6 percent; aRR, 1.67, 95 percent CI, 1.60–1.74).

In contrast, palliative care among patients who died from dementia led to higher rates of ED visits (CR, 1.2 vs 1.3 per person-year; aRR, 1.06, 95 percent CI, 1.01–1.12) and admissions to hospital (CR, 3.6 vs 2.8 per person-year; aRR, 1.33, 95 percent CI, 1.27–1.39), and a lower likelihood of dying at home or in a nursing home (72.1 percent vs 83.5 percent; aRR, 0.68, 95 percent CI, 0.64–0.73).

Such rates, however, differed depending on whether patients dying from dementia lived in the community or in a nursing home. Additionally, there was no association between healthcare use and palliative care for patients dying from dementia who lived in the community, and these individuals had a higher chance of dying at home.

“Our study supports the role palliative care has in providing high value end-of-life care to people dying from cancer and most noncancer illness,” the researchers said. “We found that palliative care might reduce healthcare use and potentially burdensome interventions near the end of life.” [Ann Intern Med 2018;168:71-72]

Of note, certain questions regarding the timing, location of initiation, and models of palliative care delivery to improve end-of-life care for patients with noncancer illness remain. Such questions include the involvement of a patient’s primary care provider in the delivery of palliative care, which is often founded on a longitudinal and trusting relationship, according to the researchers.

“Further study is also required to explain the differences found in healthcare use between patients dying from cancer and chronic organ failure and those dying from dementia,” they added.