Virtual Palliative Care: Evaluating Innovative Models of End-of-Life Care during the COVID-19 Pandemic

Importance: The Canadian healthcare system faces a significant challenge in meeting the needs of the majority of adults who wish to die at home, with relatively few home-based providers available to support them. These challenges were further magnified during the COVID-19 pandemic. In response to restrictions on in-person care, the use of virtual care, including at end-of-life, was rapidly expanded through telephone and video platforms to fill potential gaps in care delivery.

Before the pandemic, virtual end-of-life care was not widely accessible to patients, particularly for those who were unfamiliar and had limited access to technology, belonged to a racial or ethnic minority group, or were of lower socioeconomic status. Experts raised concerns that these potential care inequities may worsen with the expanded use of virtual care during the pandemic. However, there is limited research describing who received virtual palliative care and who did not, and if it can improve how people die. The goal of this program of research was to study the use and impact of virtual end-of-life care during the pandemic.

Methods: Our research used data from all adults in Ontario who were in their last 3 months of life and died between January 2018 and December 2021. This data was used to study potential differences in the changes in use and delivery models of virtual end-of-life care, the types of people who used virtual end-of-life care before and during the pandemic, how its use affected their need to go to the emergency department and to be hospitalized, and the types of physicians who were using virtual end-of-life care for their patients.

Impact and Relevance: Our research highlights the potential benefits of virtual end-of-life care in supporting access to high-quality end-of-life care and further identifies potential areas for improvement in its future use. These improvements may include tailoring the right mix of in-person and virtual end-of-life care to meet the specific needs of a person, which may be accomplished by incentivizing physicians to increase or decrease their use. Using annual patient volumes may be one efficient method to identify physicians who over or underuse virtual end-of-life care.

Many of these findings provide a valuable foundation for future research and may inform health policy to support its continued use. Virtual end-of-life care holds great promise to ensure people get the best care possible when and where they need it.

Findings

1. Increased use of virtual end-of-life care

There was a significant increase in the use of virtual end-of-life care during the pandemic compared to the pre-pandemic period. Prior to the pandemic, only 12% of people received virtual end-of-life care, whereas 88% of people received virtual end-of-life care during the pandemic.

There was levelling of the pre-existing disparities in the types of people who used virtual end-of-life care. For example, before the pandemic, virtual end-of-life care was more likely to be used by younger adults in urban settings. During the pandemic, virtual end-of-life care was more likely to be used by older adults and no more likely to occur in rural or urban care environments.

The use of virtual care was associated with the use of acute care services like the emergency department and the need for hospital admission. People who used virtual end-of-life care were more likely to visit the emergency department and be admitted to the hospital. Still, those who used virtual end-of-life care were more likely to die at home compared to people who did not – a trend that was magnified during the pandemic.

2. Diagnosis impacted use of virtual end-of-life care

We found that the type of serious illness a person had was associated with the care delivery model they received, which may reflect differences in their underlying care needs.

People with cancer predominantly received a mixed model of in-person and virtual end-of-life care, compared to those with non-cancer illnesses such as dementia or heart failure. People with dementia were more likely to receive exclusively in-person end-of-life care in their homes, and people with multiple chronic conditions were more likely to receive exclusively virtual end-of-life care compared to people with cancer.

3. Increased engagement of physicians in virtual end-of-life care

We found that the expanded use of virtual end-of-life care recruited new physicians to use it for their patients. However, certain physician behaviours, such as the number of people a physician saw per year, appeared to influence how likely a physician was to use virtual end-of-life care. Physicians who saw more patients per year were more likely to use virtual end-of-life care compared to physicians with lower annual patient volumes.