Aggressive end-of-life care among in-hospital decedents in China: differences by cancer status, timing, and associated factors

Aggressive end-of-life (EOL) care is common in hospitals, yet contemporary evidence from mainland China comparing cancer and non-cancer decedents—particularly regarding timing of interventions—is limited. To quantify Aggressive EOL care intensity and timing during terminal hospitalization among cancer and non-cancer decedents, identify associated factors, and assess temporal trends. We conducted a retrospective observational study of adult in-hospital decedents (≥ 18 years) at a tertiary teaching hospital in Nanchang, China (August 1, 2017–December 31, 2024). The primary outcome was a core Aggressive EOL care intensity score (0–5), defined as the unweighted sum of five domains (CPR-related interventions, respiratory support, renal support, circulatory support, and ICU death). Secondary outcomes were high-intensity Aggressive EOL care (score ≥ 2 and ≥ 3). Timing was assessed using population-level occurrence within ≤ 7 days before death and among recipients, the most proximal (final recorded) occurrence relative to death. Multivariable Poisson regression with robust standard errors and logistic regression were used. Temporal trends were assessed using adjusted generalized linear models. Among 3,205 decedents, 990 (30.9%) had cancer. Non-cancer decedents had higher Aggressive EOL care use across all domains and higher intensity (≥ 3 domains: 22.9% vs. 6.7%). Non-cancer status was associated with a higher core aggressive EOL care intensity score (adjusted IRR 2.22, 95% CI 1.96–2.44), and emergency admission showed the strongest association with higher intensity (IRR 1.75, 1.66–1.85). Among recipients, the most proximal CPR-related intervention occurred within ≤ 7 days in 98.2% and on the day of death in 80.4%. Temporal trends differed by cancer status (P for interaction = 0.047). Aggressive EOL care is common and occurred predominantly near death, with substantially higher multi-domain intensity among non-cancer decedents. Emergency admission emerges as a key leverage point for timely goals-of-care communication and earlier, diagnosis-agnostic palliative integration.