Disparities in End-of-life Care

A new study by University Health Network (UHN)’s Princess Margaret Cancer Centre (PM) found that the COVID-19 pandemic caused more patients with cancer to die at home and led to less receipt of specialized palliative care. The pandemic also amplified socioeconomic disparities in death at home and delivery of end-of-life care.

“Studies suggest that most patients with advanced cancer prefer to receive end-of-life care at home and to die at home,” says Dr. Camilla Zimmermann, Senior Scientist at PM and senior author of the study.

“When cancer patients can receive specialized palliative care and follow their preference to die at home, they usually enjoy a better quality of life at the end of their life and a better quality of death.”

Although the COVID-19 pandemic had a significant impact on the delivery of cancer care, less is known about its influence on the place of death, delivery of specialized palliative care, and disparities in these outcomes due to socioeconomic status.

Dr. Zimmermann’s team set out to determine whether the end-of-life experience is equitable across socioeconomic statuses and whether the pandemic played a role in increasing inequities.

“We analyzed data from a pool of over 170,000 Ontario patients who died with cancer from 2015 to 2021 to determine whether there was a change in home deaths and specialized palliative care delivery before and during the pandemic, using patient socioeconomic status as subgroups,” says Dr. Javaid Iqbal, Doctoral Student at PM and first author of the study.

“We found that both before and during the pandemic, patients with the lowest socioeconomic status were least likely to die at home and to receive palliative care at the end of life,” adds Dr. Iqbal.

Despite a substantial surge of patients who died at home during COVID, the home death increase in the lowest socioeconomic group was less marked than in other groups.

In addition, although the pandemic disrupted overall access to palliative care, this was more evident in the lowest socioeconomic group. Unlike the other groups where the surge in home death occurred both in patients receiving and not receiving palliative care, low socioeconomic patients had a significant home death increase only in those without this care.

These findings indicate that the pandemic increased socioeconomic disparities in end-of-life care and identify a need to deliver this care more broadly and equitably in the future.

“Future research should focus on the mechanisms of these disparities to develop interventions that ensure equitable and consistent access to palliative care,” concludes Dr. Zimmermann.

This work was supported by the Canadian Institutes of Health Research, Canada Graduate Scholarship, the Peterborough KM Hunter Charitable Foundation, and The Princess Margaret Cancer Foundation. Dr. Camilla Zimmermann is a Professor of Medicine at the University of Toronto.

Co-author Dr. Krzyzanowska reported being a principal investigator for trials with Eli Lilly, Exelixis, and Novartis and receiving advisory board fees from Ipsen. Co-author Dr. Lau received funding from the Health Canada Health Care Policy and Strategies Program.

Iqbal J, Moineddin R, Fowler RA, Krzyzanowska MK, Booth CM, Downar J, Lau J, Le LW, Rodin G, Seow H, Tanuseputro P, Earle CC, Quinn KL, Hannon B, Zimmermann C. Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19. JAMA Netw Open. 2024 Feb 5;7(2):e240503. doi: 10.1001/jamanetworkopen.2024.0503