Social determinants of end-of-life palliative care
Prof Siran Koroukian - Case Western Reserve University, Cleveland, USA
We looked into patterns of treatment in the last thirty days of life in patients who were dying from cancer and specifically we looked at their use of acute care services, so admission to the emergency department or to the hospital. We looked at receipt of cancer-directed treatment in that thirty day window and also admission to the ICU. We also looked at whether they died in the hospital. This study was done in the context of multi-morbidity which we defined not only just as the presence of chronic conditions but also as chronic conditions co-occurring with functional limitations and/or geriatric syndromes. We had hypothesised that multi-morbidity would be negatively associated with receipt of aggressive care in the last thirty days of life; instead what we found was that multi-morbidity was not at all associated with aggressive treatment or any treatment in the last thirty days of life. Instead aggressive care was driven to some extent by age but mostly by race, patient race. This was done in a US representative sample of participants who had died from cancer.
In patients who are dying from cancer, this is only the last thirty days of life, it is futile to give all these kinds of treatment and so there is more movement now to favour palliative care. Palliative care is some form of indicator of quality of care and therefore African-Americans or blacks in the United States were more likely to have these treatments.
Would you say that doctors are following guidelines blindly?
I wouldn’t put all the blame on doctors, I think that there are a lot of cultural issues that need to be worked out here. There needs to be some education going in to certain ethnic groups to say this is what palliative care is about and maybe aggressive care is not the way to go here in the last thirty days of life.
What are your conclusions?
The important message is that if palliative care is not driven by multi-morbidity and it’s driven more by cultural issues then the implication is that there should be public education about palliative care and maybe targeted and well-designed interventions to address the cultural issues in certain ethnic groups to address this problem.
What would be your message to doctors?
With doctors of course patient preference is going to be very important and what the patient wants going forward into the end of life phase. But doctors should probably be educating their patients as well about maybe the futility of this kind of treatment at the end of life, especially because it tends to be very costly.