Study examines end-of-life care for cancer patients
One in three patients with advanced cancer spend their final days in hospitals receiving costly, aggressive treatments they may not want, according to a major national study released Tuesday.
Researchers at the Dartmouth Atlas of Health Care, whose work on hospital spending has been cited by the Obama administration, reviewed a sample of 20% of Medicare beneficiaries nationwide with advanced cancer who died between 2003 and 2007, including patients at 65 California hospitals.
Of nearly 240,000 terminally ill patients studied, about 29% died in hospitals. The likelihood of dying in a hospital varied significantly depending on where the person was treated, the report found.
In California, Los Angeles County had the highest percentage of advanced cancer patients dying in hospitals at about 41%, followed by Fresno (39%), Bakersfield (37%), San Francisco (36%) and Modesto (36%).
“We as physicians often make assumptions about what patients and their families want,” said Dr. David C. Goodman, the report’s lead author. “We are particularly uncomfortable with sharing the news that a cure is unlikely. But what patients really want is for physicians to be honest with them and share the full range of treatment choices.”
Dartmouth’s past reports have been widely circulated on Capitol Hill, generating debate but few policy changes. The latest report has the potential to spark meaningful conversations about end-of-life care, but it could also fuel concern about rationing healthcare if lawmakers use it to propose Medicare cuts or incentives for doctors to discuss less expensive — and less aggressive — treatment with terminal patients, he said.
“Having payment for end-of-life conversations was exactly what led people to start screaming about death panels,” said Stephen Zuckerman, a health economist and senior fellow at the Washington, D.C.-based Urban Institute. “If you provide financial incentives for people to move into less aggressive treatment, is that the reaction you’re going to get?”
A little more than half of patients surveyed used hospice care during their last month of life, but researchers found that in some cases referrals came so close to death that they were unlikely to have provided much assistance. Terminally ill cancer patients in L.A. County were less likely to be cared for in a hospice at the end of their life than the national average, the report found, with about 40% referred to hospice care.
Barbara Hayes, 70, of Los Angeles was diagnosed with metastatic colon cancer in May and met with a hospice worker Tuesday after suffering a heart attack that sent her to Cedars-Sinai Medical Center’s intensive care unit. She signed paperwork refusing life-sustaining, aggressive treatment and said she was leaning toward hospice care.
“I want to just let it go and let nature take its course,” said Hayes, who retired from an interior design firm and is covered by Medicare. “I don’t want tubes down my throat.”
Susan Negreen, executive director of the Sacramento-based California Hospice and Palliative Care Assn., said the Dartmouth report underscores the need for hospice awareness. Statewide, about 35% of Medicare deaths were in hospice, slightly below the national average of about 37% as of 2008, the most recent year for which information was available.
“It’s very hard for people to realize they have run out of options,” Negreen said. “There’s always one more round of chemo or one more procedure they can do.”
The report contrasted medical interventions at big-city hospitals with facilities in mid-sized or small cities, often in the Midwest. Cancer patients were more likely to receive “aggressive life-sustaining treatment” — including CPR, feeding and breathing tubes — during the last weeks of their lives in Manhattan (18%), Los Angeles (18%), Orange County (17%) and Chicago (16%) as compared with Minneapolis (4%), Des Moines (5%) and Seattle (6%).
About 6% of the patients nationwide received chemotherapy during their last two weeks of life, 7% in Los Angeles County, the study showed. In some areas, including Santa Barbara County, the rate exceeded 10%.
Dartmouth researchers have drawn criticism in the past for ignoring regional differences in patient health and the cost of providing care and for focusing on the cost of care instead of other measures of hospital quality.
Dr. Michael Langberg, chief medical officer at Cedars-Sinai, said the report was useful for discussion but “I remain concerned about taking their kind of research and from that leaping to policy.”
Goodman, the report’s author who is also director of Dartmouth’s Center for Health Policy Research, said researchers were not “looking to control costs on the backs of people with advanced cancer” or to penalize hospitals for aggressive treatment.
He said the goal of the report was to promote palliative care, which aims to minimize patient suffering and promote quality of life, but is not covered as comprehensively as hospital care by the government private insurers. Medicare covers hospice services but requires patients who choose that option to then forgo most hospital treatment.
Federal officials are offering three-year grants to 15 hospice programs nationwide to serve patients without requiring them to give up hospital treatment.
Dr. Tom Rosenthal, chief medical officer for the UCLA Health System, said the study raises important questions about how doctors manage end-of-life care. The five UC hospitals recently joined Cedars-Sinai in an effort to standardize palliative-care programs and provide patient educators to explain intensive care and other end-of-life options. The project will be paid for by a three-year, $9.9-million federal stimulus grant.
“There really are nationally no norms for end-of-life treatment,” Rosenthal said, but he cautioned that comparisons among hospitals are complicated by their mix of patients. “The people who want to die peacefully at home are not the patients pressuring their doctors to send them to a major urban care center.”
Cheryl Stratos, 46, of McLean, Va., flies across the country each month to participate in a clinical trial at UCLA’s Jonsson Comprehensive Cancer Center in Westwood to treat her metastatic melanoma.
Stratos, who runs a marketing firm and has a 13-year-old son, said she is not sure whether she would want life-sustaining treatment — her energy has been focused on seeking care, first at Georgetown University Hospital, then Memorial Sloan-Kettering Cancer Center in New York City and UCLA.
“It all depends on where I am in the process,” she said.