Goals of care and advance directives: A 1-year retrospective analysis of a tertiary centre in Saudi Arabia

Background: Despite its limited therapeutic value, high costs and the fact that it can compromise a patient's quality of life, aggressive care continues to be provided at the end of life. It has been associated with a significant symptom burden for patients, a greater use of healthcare resources, delay in accessing palliative care programmes and personal/family and healthcare costs. Aim: To investigate sociodemographic, clinical and community healthcare service factors associated with aggressive end-of-life care across malignant and non-malignant conditions. Method: A 1-year retrospective analysis was conducted in a tertiary care centre in Saudi Arabia. All deaths of adult patients that occurred between 1 January, 2023 and 1 January, 2024, were included. Data were retrieved from medical charts, including sociodemographics, medical history, invasive medical interventions and use of healthcare services in the last 3 months of life. Results: The study included 590 adults (mean age 59.6 years; 52.2% male), with 62% diagnosed with malignancy. The majority (71%) had one or more chronic comorbidities. In their last 90 days, 48.6% were admitted to the intensive care unit. Advance directives were present for only half of the patients included in this study. Non-malignant patients received significantly more aggressive end-of-life care, including intubation and cardiopulmonary resuscitation. Palliative care referrals were low overall (48.1%), but higher in cases of malignancy (70.5%). Patients with involvement in a palliative care team showed a lower symptom burden and less aggressive treatment. Conclusions: These findings suggest unequal access to end-of-life advocates for earlier palliative care referral, which could reduce aggressive treatments, especially for younger patients with non-malignant diseases. Non-cancer referral rates were low, highlighting a need for further collaboration and integration with palliative care services.