Palliative Care Reduces Hospital Death Risk in Multiple Sclerosis

The Challenge of End-of-Life Transitions in Multiple Sclerosis

Patients with progressive neurological conditions, including multiple sclerosis (MS), face complex symptom burdens that often require specialized interdisciplinary support to maintain quality of life [1]. While integrated palliative care can reduce symptom intensity and improve patient satisfaction, high-quality evidence to guide standardized service development for these long-term conditions remains limited [2]. Clinicians often struggle to identify the optimal timing and specific clinical triggers for specialist palliative referral, a process that currently relies heavily on expert consensus rather than robust longitudinal data [3]. Furthermore, patients with severe disease frequently require intensive cross-sectoral coordination to manage multidimensional needs, yet the transition from disease-modifying management to end-of-life care is often poorly defined [4]. To address this gap, a retrospective cohort study recently examined healthcare utilization patterns to clarify how specialist involvement and geographic factors influence the final years of life for this vulnerable population.

Demographics and Specialist Utilization Patterns

To evaluate end-of-life care trajectories, researchers conducted a retrospective cohort study using linked health administrative databases in Ontario, Canada. The study population included all adults who died in the province between April 2016 and March 2020. To ensure diagnostic accuracy, the authors identified MS cases using a validated algorithm, a statistical tool that applies standardized criteria to administrative data to accurately flag specific diagnoses. This methodology allowed for a comprehensive comparison of healthcare utilization between 1,975 MS decedents and the remaining 500,904 individuals in the cohort. Demographic data revealed that the MS population reached the end of life significantly earlier than the general population. The mean age of MS decedents was 68 years, compared to a mean age of 77 years in the control group. Within the MS cohort, 66.4% of the decedents were female. Notably, the MS decedents had fewer comorbidities (co-occurring chronic medical conditions) than the non-MS decedents. This suggests their clinical needs at the end of life were driven primarily by their progressive neurological disease rather than a high burden of age-related systemic illnesses. Specialist involvement showed a marked decline as patients approached death, highlighting a critical shift in the focus of care. While 49.4% of MS decedents had outpatient neurology visits within the last five years of life, this specialized oversight was rarely maintained during the terminal phase. The data showed that outpatient neurology visits plummeted to 2.7% in the last month of life. This steep reduction indicates that as patients enter their final weeks, management often transitions away from the neurologists who guided their care for years, potentially creating a gap in specialized symptom control precisely when patients need it most.

Palliative Care Access and Clinical Predictors

Overall utilization of palliative care services was comparable between the two groups, with palliative care use reaching 58.0% in MS decedents compared to 56.9% in non-MS decedents. While the total proportion of patients receiving these services was similar, the timing of initial involvement differed. Specifically, palliative care involvement occurred in the last five years of life for 61.9% of MS decedents versus 59.6% of non-MS decedents. This suggests that patients with MS are identified for supportive care slightly earlier in their disease trajectory than the general population. For clinicians, this early integration is highly relevant, as it provides a longer window for complex symptom management and advanced care planning before the terminal phase begins. Several clinical factors served as strong predictors for the receipt of palliative care among the MS cohort. The researchers determined that higher comorbidity was associated with greater odds of receiving palliative care (odds ratio [OR] 3.64, 95% confidence interval [CI] 2.50 to 5.29). This indicates that patients with more complex medical profiles are more readily identified by healthcare teams as requiring multidisciplinary support. Furthermore, the data showed that increased outpatient visits to urology were associated with greater odds of receiving palliative care (OR 1.47, 95% CI 1.20 to 1.80). For the practicing physician, frequent urology consultations likely serve as a proxy for advanced disease progression, particularly regarding severe neurogenic bladder dysfunction. These specialist visits may act as a critical touchpoint where the escalating need for palliative intervention is recognized and a formal referral is finally initiated.

Impact of Geography and Timing on Site of Death

Geographic location significantly influenced the end-of-life trajectory for patients with MS. Using multivariable regression analysis, a statistical technique that isolates the independent effect of multiple variables simultaneously, the researchers revealed that rural residence was associated with increased odds of hospital death (OR 1.81, 95% CI 1.21 to 2.70). This finding suggests that patients in non-urban areas face substantial barriers to accessing the home-based support systems necessary to facilitate a death outside of the acute care setting. Furthermore, the researchers found that rural residence was associated with lower odds of receiving palliative care (OR 0.74, 95% CI 0.55 to 0.99), highlighting a critical disparity in service delivery for patients living outside of major metropolitan centers. The timing of palliative intervention proved to be a decisive factor in determining the site of death. The study demonstrated that receiving palliative care within the last five years of life reduced the odds of hospital death (OR 0.47, 95% CI 0.37 to 0.60). This 53 percent reduction in the odds of dying in an acute care setting underscores the clinical importance of early integration of supportive services. For the practicing clinician, these data confirm that initiating palliative care discussions well before the terminal phase can facilitate a successful transition toward home-based or hospice care, aligning medical management with patient preferences to avoid institutionalized death. Addressing these disparities requires a proactive approach to care coordination, particularly as specialist involvement wanes in the final months of life. Given the sharp decline in neurology visits observed near the end of life, the researchers emphasize that earlier palliative integration, specifically through neuropalliative care models, could mitigate the risks associated with rural residence and late-stage care transitions. Ensuring that patients in rural areas have equitable access to these specialized services is essential for improving the quality of end-of-life care and reducing the reliance on hospital resources during the final stages of multiple sclerosis.

References

1. Chan LML, Yan OY, Lee JJJ, et al. Effects of Palliative Care for Progressive Neurologic Diseases: A Systematic Review and Meta-Analysis.. Journal of the American Medical Directors Association. 2023. doi:10.1016/j.jamda.2022.11.001

2. Gao W, Wilson R, Hepgul N, et al. Effect of Short-term Integrated Palliative Care on Patient-Reported Outcomes Among Patients Severely Affected With Long-term Neurological Conditions: A Randomized Clinical Trial.. JAMA network open. 2020. doi:10.1001/jamanetworkopen.2020.15061

3. McConvey K, Kazazian K, Iansavichene AE, Jenkins ME, Gofton TE. Triggers for Referral to Specialized Palliative Care in Advanced Neurologic and Neurosurgical Conditions: A Systematic Review.. Neurology. Clinical practice. 2022. doi:10.1212/CPJ.0000000000001159

4. Golla H, Dunkl V, Dorr A, et al. Communication, Coordination, and Security for People With Multiple Sclerosis (COCOS-MS): A Randomized, Phase II Trial of Cross-sectoral Care and Case Management.. Deutsches Arzteblatt international. 2025. doi:10.3238/arztebl.m2025.0097