Immigrants may get more intense care at end of life

LONDON: Recent immigrants may be more likely than other people to receive aggressive treatment in their last six months of life and die in intensive care, a Canadian study suggests.

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.

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.”