Association between Chinese or South Asian ethnicity and end-of-life care in Ontario, Canada

Abstract

Background: Ethnicity may be associated with important aspects of end-of-life care, such as what treatments are received, access to palliative care and where people die. However, most studies have focused on end-of-life care of white, Hispanic and black patients. We sought to compare end-of-life care delivered to people of Chinese and South Asian ethnicity with that delivered to others from the general population, in Ontario, Canada.

Methods: In this population-based cohort study, we included all people who died in Ontario, Canada, between Apr. 1, 2004, and Mar. 31, 2015. People were identified as having Chinese or South Asian ethnicity on the basis of a validated surname algorithm. We used modified Poisson regression analyses to assess location of death and care received in the last 6 months of life.

Results: We analyzed 967 339 decedents, including 18 959 (2.0%) of Chinese and 11 406 (1.2%) of South Asian ethnicity. Chinese (13.6%) and South Asian (18.5%) decedents were more likely than decedents from the general population (10.1%) to die in the intensive care unit (ICU). The adjusted relative risk of dying in intensive care was 1.21 (95% confidence interval [CI] 1.15 to 1.27) for Chinese and 1.25 (95% CI 1.20 to 1.30) for South Asian decedents. In their last 6 months of life, decedents of Chinese and South Asian ethnicity experienced significantly more ICU admission, hospital admission, mechanical ventilation, dialysis, percutaneous feeding tube placement, tracheostomy and cardiopulmonary resuscitation than the general population.

Interpretation: Decedents of Chinese and South Asian ethnicity in Ontario were more likely than decedents from the general population to receive aggressive care and to die in an ICU. These findings may be due to communication difficulties between patients and clinicians, differences in preferences about end-of-life care or differences in access to palliative care services.

Figure 1:

Forest plot showing the ratio of the proportions of decedents from each ethnicity experiencing each of the major study outcomes. Each comparison shows the relative risk (RR) of experiencing the outcome among Ontario decedents of either Chinese or South Asian ethnicity compared with the Ontario decedent general population. Each RR is derived from a modified Poisson regression model with generalized estimating equations incorporating age, sex, geography, socioeconomic position, cause of death and immigration status. Relative risks greater than 1 correspond to an increased RR of the outcome among Ontarians of Chinese or South Asian ethnicity. Note: CI = confidence interval, CPR = cardiopulmonary resuscitation, ICU = intensive care unit. *Interventions received in final 6 months of life.

Figure 2:

Forest plot showing the coefficients of the 2 interaction analyses (age by ethnicity and immigration status by ethnicity) with respect to the outcome of death in the intensive care unit (ICU) compared with all other locations. Each row shows the relative risk (RR) of being in the ICU at the time of death for decedents within the described subgroup comparing Ontario decedents of either Chinese or South Asian ethnicity with Ontario decedents from the general population. Each coefficient is derived from a regression model with generalized estimating equations incorporating age, sex, geography, socioeconomic position, cause of death and immigration status. Note: CI = confidence interval. *Coefficients for the interaction between immigration status and ethnicity are RRs from a modified Poisson regression model, and coefficients for the interaction between age and ethnicity are odds ratios from a logistic regression model owing to convergence difficulties with a modified Poisson model. Relative risks greater than 1 correspond to an increased RR of being in intensive care at death among Ontarians of Chinese or South Asian ethnicity.