Delivery of palliative care in the last year of life to individuals receiving maintenance dialysis: a population-level cross-sectional study

Rationale and 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 and 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.