Yarnell Christopher J, Fu Longdi, Manuel Doug, Tanuseputro Peter, Stukel Therese, Pinto Ruxandra, Scales Damon C, Laupacis Andreas, Fowler Robert A
University of Toronto Department of Medicine, Toronto, Ontario, Canada.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
JAMA. 2017 Oct 17;318(15):1479-1488. doi: 10.1001/jama.2017.14418.
People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.
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.
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.
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.
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.
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.
移民面临独特的健康素养、沟通及医疗系统导航挑战，且可能有多样偏好影响临终关怀。
研究加拿大移民生命最后6个月所接受的临终关怀。
设计、背景与参与者：这项基于人群的队列研究（2004年4月1日至2015年3月31日）纳入了加拿大安大略省的967013名死者，利用健康与移民数据库间的有效关联来识别移民（自1985年起）及长期居民队列。
1985年至2015年间移民到加拿大的所有死者被归类为新移民，亚组分析评估移民时间及出生地区与临终关怀的关联。
死亡地点及生命最后6个月接受的护理强度。分析采用带广义估计方程的修正泊松回归，对年龄、性别、社会经济地位、死亡原因、城乡居住情况及既往合并症进行校正。
在967013名死者中，47514人（5%）自1985年起移民，性别、社会经济地位、城市（与农村相比）居住情况及死亡原因相似，但长期居民比移民死者年龄更大（年龄中位数[四分位间距]，75[58 - 84]岁对80[68 - 87]岁）。在对年龄、性别、收入、地理位置及死亡原因差异进行校正后，新移民死者总体上更有可能在重症监护室死亡（15.6%对10.0%；差异为5.6%；95%置信区间，5.2% - 5.9%）（相对风险，1.30；95%置信区间，1.27 - 1.32）。在生命的最后6个月，新移民死者经历了更多的重症监护入院（24.9%对19.2%；差异为5.7%；95%置信区间，5.3% - 6.1%）、医院入院（72.1%对68.2%；差异为3.9%；95%置信区间，3.5% - 4.3%）、机械通气（21.5%对13.6%；差异为7.9%；95%置信区间，7.5% - 8.3%）、透析（5.5%对3.4%；差异为2.1%；95%置信区间，1.9% - 2.3%）、经皮饲管置入（5.5%对3.0%；差异为2.5%；95%置信区间，2.3% - 2.8%）及气管切开（2.3%对1.1%；差异为1.2%；95%置信区间，1.1% - 1.4%）。与长期居民相比，新移民在重症监护室死亡的相对风险因新移民出生地区而异，从北欧和西欧出生者的0.84（95%置信区间，0.74 - 0.95）到南亚出生者的1.96（95%置信区间，1.89 - 2.05）。
在加拿大安大略省的死者中，与其他居民相比，新移民接受积极治疗并在重症监护室死亡的可能性显著更高。需要进一步研究以了解这种关联背后的机制。
