Association Between Immigrant Status and End-of-Life Care in Ontario, Canada | Critical Care Medicine | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
World Health Organization. WHO definition of palliative care. Accessed March 21, 2016.
Heyland  DK, Dodek  P, Rocker  G,  et al; Canadian Researchers End-of-Life Network(CARENET).  What matters most in end-of-life care: perceptions of seriously ill patients and their family members.  CMAJ. 2006;174(5):627-633.PubMedGoogle ScholarCrossref
Heyland  DK, Cook  DJ, Rocker  GM,  et al; Canadian Researchers at the End of Life Network (CARENET).  Defining priorities for improving end-of-life care in Canada.  CMAJ. 2010;182(16):E747-E752.PubMedGoogle ScholarCrossref
Frost  DW, Cook  DJ, Heyland  DK, Fowler  RA.  Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review.  Crit Care Med. 2011;39(5):1174-1189.PubMedGoogle ScholarCrossref
Central Intelligence Agency. The World Factbook: country comparison: net migration rate. Accessed March 21, 2016.
Statistics Canada. Population and dwelling count highlight tables, 2011 census. Published January 7, 2016. Accessed March 21, 2016.
Fuller-Thomson  E, Noack  AM, George  U.  Health decline among recent immigrants to Canada: findings from a nationally-representative longitudinal survey.  Can J Public Health. 2011;102(4):273-280.PubMedGoogle Scholar
Sanmartin  C, Ross  N.  Experiencing difficulties accessing first-contact health services in Canada: Canadians without regular doctors and recent immigrants have difficulties accessing first-contact healthcare services: reports of difficulties in accessing care vary by age, sex and region.  Healthc Policy. 2006;1(2):103-119.PubMedGoogle Scholar
Tu  JV, Chu  A, Rezai  MR,  et al.  The Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada: the CANHEART Immigrant Study [published online August 31, 2015].  Circulation.PubMedGoogle Scholar
Lackan  NA, Eschbach  K, Stimpson  JP, Freeman  JL, Goodwin  JS.  Ethnic differences in hospital place of death among older adults in California.  Med Care. 2009;47:138-145.PubMedGoogle ScholarCrossref
Bosma  H, Apland  L, Kazanjian  A.  Cultural conceptualizations of hospice palliative care: more similarities than differences.  Palliat Med. 2010;24(5):510-522.PubMedGoogle ScholarCrossref
Unroe  KT, Greiner  MA, Johnson  KS, Curtis  LH, Setoguchi  S.  Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure.  Am Heart J. 2012;163(6):987-993.e3.PubMedGoogle ScholarCrossref
Cruz-Oliver  DM, Talamantes  M, Sanchez-Reilly  S.  What evidence is available on end-of-life (EOL) care and Latino elders? a literature review.  Am J Hosp Palliat Care. 2014;31(1):87-97.PubMedGoogle ScholarCrossref
Hanchate  A, Kronman  AC, Young-Xu  Y, Ash  AS, Emanuel  E.  Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites?  Arch Intern Med. 2009;169(5):493-501.PubMedGoogle ScholarCrossref
Smith  AK, Sudore  RL, Pérez-Stable  EJ.  Palliative care for Latino patients and their families: whenever we prayed, she wept.  JAMA. 2009;301(10):1047-1057, E1.PubMedGoogle ScholarCrossref
Chiu  M, Lebenbaum  M, Lam  K,  et al.  Describing the linkages of the immigration, refugees and citizenship Canada permanent resident data and vital statistics death registry to Ontario’s administrative health database.  BMC Med Inform Decis Mak. 2016;16(1):135.PubMedGoogle ScholarCrossref
Juurlink  D, Preyra  C, Croxford  R,  et al.  Canadian Institute for Health Information Discharge Abstract Database: A Validation Study. Toronto, ON, Canada: Institute for Clinical Evaluative Sciences; 2006.
World Health Organization. ICD-10 version: 2016. Accessed March 21, 2016.
Glazier  RH, Zagorski  BM, Rayner  J.  Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10. Toronto, ON, Canada: Institute for Clinical Evaluative Sciences; 2012: 41.
Yelland  LN, Salter  AB, Ryan  P.  Performance of the modified Poisson regression approach for estimating relative risks from clustered prospective data.  Am J Epidemiol. 2011;174(8):984-992.PubMedGoogle ScholarCrossref
Adames  HY, Chavez-Dueñas  NY, Fuentes  MA, Salas  SP, Perez-Chavez  JG.  Integration of Latino/a cultural values into palliative health care: a culture centered model.  Palliat Support Care. 2014;12(2):149-157.PubMedGoogle ScholarCrossref
Ebrahim  S, Bance  S, Bowman  KW.  Sikh perspectives towards death and end-of-life care.  J Palliat Care. 2011;27(2):170-174.PubMedGoogle Scholar
Dobbs  D, Park  NS, Jang  Y, Meng  H.  Awareness and completion of advance directives in older Korean-American adults.  J Am Geriatr Soc. 2015;63(3):565-570.PubMedGoogle ScholarCrossref
Garrido  MM, Harrington  ST, Prigerson  HG.  End-of-life treatment preferences: a key to reducing ethnic/racial disparities in advance care planning?  Cancer. 2014;120(24):3981-3986.PubMedGoogle ScholarCrossref
Higginson  IJ, Gomes  B, Calanzani  N,  et al; Project PRISMA.  Priorities for treatment, care and information if faced with serious illness: a comparative population-based survey in seven European countries.  Palliat Med. 2014;28(2):101-110.PubMedGoogle ScholarCrossref
Sprung  CL, Cohen  SL, Sjokvist  P,  et al; Ethicus Study Group.  End-of-life practices in European intensive care units: the Ethicus Study.  JAMA. 2003;290(6):790-797.PubMedGoogle ScholarCrossref
Phua  J, Joynt  GM, Nishimura  M,  et al; ACME Study Investigators and the Asian Critical Care Clinical Trials Group.  Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia.  JAMA Intern Med. 2015;175(3):363-371.PubMedGoogle ScholarCrossref
Moss  KO, Williams  IC.  End-of-life preferences in Afro-Caribbean older adults: a systematic literature review.  Omega (Westport). 2014;69(3):271-282.PubMedGoogle ScholarCrossref
Sharma  RK, Khosla  N, Tulsky  JA, Carrese  JA.  Traditional expectations versus US realities: first- and second-generation Asian Indian perspectives on end-of-life care.  J Gen Intern Med. 2012;27(3):311-317.PubMedGoogle ScholarCrossref
Wright  AA, Stieglitz  H, Kupersztoch  YM,  et al.  United states acculturation and cancer patients’ end-of-life care.  PLoS One. 2013;8(3):e58663.PubMedGoogle ScholarCrossref
Jonnalagadda  S, Lin  JJ, Nelson  JE,  et al.  Racial and ethnic differences in beliefs about lung cancer care.  Chest. 2012;142(5):1251-1258.PubMedGoogle ScholarCrossref
Kavalieratos  D, Corbelli  J, Zhang  D,  et al.  Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis.  JAMA. 2016;316(20):2104-2114.PubMedGoogle ScholarCrossref
Mack  JW, Paulk  ME, Viswanath  K, Prigerson  HG.  Racial disparities in the outcomes of communication on medical care received near death.  Arch Intern Med. 2010;170(17):1533-1540.PubMedGoogle ScholarCrossref
Volandes  AE, Paasche-Orlow  M, Gillick  MR,  et al.  Health literacy not race predicts end-of-life care preferences.  J Palliat Med. 2008;11(5):754-762.PubMedGoogle ScholarCrossref
White  DB, Ernecoff  N, Buddadhumaruk  P,  et al.  Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision makers of critically ill patients.  JAMA. 2016;315(19):2086-2094.PubMedGoogle ScholarCrossref
Baicker  K, Chandra  A, Skinner  JS.  Geographic variation in health care and the problem of measuring racial disparities.  Perspect Biol Med. 2005;48(1)(suppl):S42-S53.PubMedGoogle ScholarCrossref
Bach  PB, Schrag  D, Begg  CB.  Resurrecting treatment histories of dead patients: a study design that should be laid to rest.  JAMA. 2004;292(22):2765-2770.PubMedGoogle ScholarCrossref
Original Investigation
Caring for the Critically Ill Patient
October 17, 2017

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada

Author Affiliations
  • 1University of Toronto Department of Medicine, Toronto, Ontario, Canada
  • 2Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  • 3University of Ottawa, Ottawa, Ontario, Canada
  • 4Bruyere Research Institute, Ottawa, Ontario, Canada
  • 5Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 6Programme in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 7Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 8Li Ka Shing Knowledge institute of St Michael’s Hospital, Toronto, Ontario, Canada
JAMA. 2017;318(15):1479-1488. doi:10.1001/jama.2017.14418
Key Points

Question  Do recent immigrant patients experience different end-of-life care than long-standing resident patients?

Findings  In this cohort study that included 967 013 patients, recent immigrant patients were more likely to be in the intensive care unit when they died and were more likely to receive invasive procedures in the last 6 months of life including hospital admission, intensive care unit admission, mechanical ventilation, tracheostomy, dialysis, or percutaneous feeding tube placement. These outcomes varied most significantly according to region of origin rather than socioeconomic position, language ability on arrival, or education level on arrival.

Meaning  Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.


Importance  People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.

Objective  To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.

Design, Setting, and Participants  This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.

Exposures  All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.

Main Outcomes and Measures  Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.

Results  Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.

Conclusions and Relevance  Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.