Place of Care Trajectories in the Last Two Weeks of Life: A Population-Based Cohort Study of Ontario Decedents

Abstract

Background/objectives: Place of death is a commonly reported indicator of palliative care quality, but does not provide details of service utilization near end of life. This study aims to explore place of care trajectories in the last two weeks of life in a general population and by disease cohorts.

Design/setting: A retrospective population-based cohort study using linked administrative-health data to examine Ontario decedents between April 1, 2010 and December 31, 2012.

Measurements: Place of care trajectories in the last two weeks of life.

Results: We identified 235,159 decedents. Of which, 215,533 represented the major cohorts of our analysis-cancer (32%), frailty (29%), and organ failure (31%). Sixty-one percent of all decedents died in hospital-based settings. Place of care utilization trends show us a marked increase in use of palliative-acute hospital care (13%-26%) and acute hospital care (12%-25%) and a small decrease in community care use (15%-12%) in the last two weeks of life. Those with cancer were the largest users of palliative-acute hospital care, while those with organ failure were the largest users of acute-hospital care.

Conclusions: Place of care trajectories show a marked rise in care in hospital-based settings from 29% to 61% in the last two weeks of life. Nearly half of all hospital deaths had palliative care as the main service provided. Place of care trajectories differ greatly by disease cohort. Exploring place of care trajectories in the last two weeks of life can illuminate end-of-life utilization patterns not evident when reporting solely place of death.

Keywords: community based care; end-of-life care; hospital-based care; palliative care; place of care trajectories; service utilization.

FIG. 1.

Place of care trajectories in the last two weeks of life among overall study population. n = 235,159 (cancer, organ failure, frailty, sudden death, and other). Hierarchy was applied here.

FIG. 2.

Place of care trajectories in the last two weeks of life among three major disease cohorts (cancer, organ failure, and frailty). n = 215,533. No hierarchy applied here.