Dartmouth Report on End of Life Cancer Care
By MERRILL GOOZNER,
Posted: November 17, 2010
Here are a few facts to enliven the next public discussion about death panels.
A new analysis of Medicare claims by researchers at Dartmouth University found that nationwide nearly one in three cancer patients died in hospitals or in intensive care, the most expensive form of end-of-life care and contrary to most patients’ wishes. Nearly half are not offered hospice care, while one in 11 received life-extending treatments like tube feeding.
There were also huge variations in end-of-life treatment. More than 40 percent of dying patients were put in a hospital’s intensive care unit in the last month of life in cities like Los Angeles, Miami, Huntsville, Alabama, and McAllen, Texas, while less than 15 percent of terminal cancer patients had that as part of their final experience in cities like Minneapolis, Madison, Wisconsin, and Portland, Maine.
“Studies are very consistent in showing that in 80 percent of cases, those patients who are thinking about end of life or are close to end of life strongly want to be in more homelike settings,” said David Goodman, an investigator with the Dartmouth Atlas of Health, which studies regional variations in care using Medicare claims. “Instead of a pattern of care that reflected those desires, we found that geography is destiny.”
The study also compared care at the nation’s leading academic medical centers, where one would expect comparable high levels of care and rigorous adherence to best practices for patients, who often arrive on their doorsteps looking for a miracle from the leading oncologists who practice at those institutions. Yet even here there was wide variations in care.
For instance, Lenox Hill Hospital in Manhattan and Cedars-Sinai Medical Center in Los Angeles gave chemotherapy in the last two weeks life to 12.2 percent and 11.5 percent of patients, respectively. Cleveland Clinic (2.9 percent) and Johns Hopkins Hospital (3.8 percent), on the other hand, were far less likely to engage in what some have dubbed “heroic” interventions. The average nationwide was 6 percent.
“The reality is that everyone wants to be cured of their cancer,” Goodman said. “We as physicians often make assumptions about what patients and families want for their lives. We’re very uncomfortable about telling people that cure is unlikely.”
Recent studies have shown that patients receiving more intensive care when battling terminal cancer do not fare better than patients who accept hospice or palliative care. In fact, one recent study of lung cancer patients published in the New England Journal of Medicine showed they actually lived longer if they didn’t receive chemotherapy in the last weeks of life and spent their final months in hospice receiving palliative care.
The stakes for Medicare in reducing variations in cancer care that do not improve outcomes are huge. The nation spent over $104 billion on cancer care in 2006. Costs are soaring due to many of the latest cancer drugs costing $10,000 or more a month, even though they only extend life for a few weeks or months. Roughly two-thirds of cancer patients are over 65 and thus eligible for Medicare.