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 Even after researchers accounted for other factors that can
influence end-of-life care such as income, age and cause of death,
recent immigrants were 30 percent more likely to die in intensive
care units, the study found.
They were also more likely to be admitted to the hospital in their
last six months of life, and more likely to have machines helping
them eat and breathe, researchers report in JAMA.
“The perception - I think often a mistaken perception - is that more
procedures and machines represent better care, when in fact it
doesn’t reflect care that would address patients’ and families’
fundamental needs at the end of life,” said senior study author Dr.
Robert Fowler of the Dalla Lana School of Public Health at the
University of Toronto.
While the study didn’t assess why recent immigrants received
different care than citizens or longtime residents, a lack of
awareness about care options outside the hospital and poor
communication may both play a role, Fowler said by email.
“We need to do better in our approach to end-of-life care for
everyone,” Fowler said.
For the study, researchers examined data on 967,013 people who died
in Ontario from 2004 to 2015. Out of this group, 47,515, or 5
percent, were classified as recent immigrants who arrived in the
country in 1985 or later.
Half of the recent immigrants died by age 75, compared to a typical
longevity of around 80 for longtime residents, the study found.
Roughly 16 percent of recent immigrants died in intensive care,
compared to 10 percent of longtime residents.
In the last six months of life, 72 percent of immigrants were
admitted to the hospital, compared to 68 percent of other people.
Immigrants were also more likely to be admitted to intensive care
units.
Roughly 6 percent of recent immigrants received dialysis or feeding
tubes near the end of life, about twice the proportion of longtime
residents that got these interventions.
About 2 percent of immigrants got what’s known as a tracheostomy, a
procedure to place a breathing tube through a hole in the neck; this
was also about twice as likely for immigrants as for longtime
residents.
Mechanical ventilation to aid breathing was provided to 22 percent
of immigrants and just 14 percent of other people, the study also
found.
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Immigrants’ region of origin also appeared to influence their
treatment, with less aggressive care provided to people from
Northern and Western Europe and more intensive interventions given
to people from South Asia.
One limitation of the study is that researchers lacked data on
disease severity and other individual patient characteristics that
might influence the intensity of care, the authors note.
It’s also possible that differences in care found in Canada, with
universal health insurance for the entire population, might be
magnified in the U.S. or other countries where costs and insurance
status can influence care, Fowler said.
A variety of factors may influence end-of-life care for immigrants,
including whether they have family members who can advocate on their
behalf, their cultural beliefs about dying, and language barriers
that prevent them from understanding treatment options or
communicating their preferences, said Michael Harhay, author of an
accompanying editorial and fellow at the Palliative and Advanced
Illness Research Center at the Perelman School of Medicine at the
University of Pennsylvania in Philadelphia.
“Understanding the mechanisms by which immigrants get admitted to
hospitals is a missing piece to this story and may provide insight
into the role of limited resources and barriers to palliative care,”
Harhay said by email.
“Differences in treatment may stem from differences in knowledge,”
Harhay added. “So it is essential for clinicians to inform patients
of both their prognosis and management options.”
SOURCE: http://bit.ly/2y208b6 JAMA, online October 2, 2017.
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