While most older people say they don’t want aggressive care at the end of life, many get it anyway.
Care in the last month of life for Medicare patients with advanced cancer typically is even more aggressive in the Philadelphia area than in the nation as a whole, concludes a report from the Dartmouth Atlas of Health Care, which studies regional differences in care. It released a report last week that showed the percentage of cancer patients who died in hospitals in 2010, or were hospitalized or in an intensive care unit in their last month.
Oddly, participation in hospice, which should relieve symptoms rather than prolong life, is above average in the Philadelphia area. Throughout the nation, though, the average patient waits until the last week or two to join hospice.
The Dartmouth researchers believe the regional variations reflect differing physician practices and available resources rather than patient preferences or quality.
The conclusion is that many patients here are being overtreated and are not communicating well with doctors, said David Goodman, coprincipal investigator of the Dartmouth Atlas.
“I think most people would agree that most health-care systems have got some real work to do,” he said. “Patients have no idea what is the style of care in the place that they’re receiving care, and it’s not easily identifiable.”
He said doctors find it hard to pull back as their patients worsen.
The study included hospitals that cared for at least 80 Medicare patients with advanced cancer.
A survey of Medicare beneficiaries published in 2007 found that when faced with a hypothetical terminal illness, 86 percent wanted to die at home, compared with 9 percent in a hospital and 5 percent in a nursing home.
But many families may lack the resources to care for relatives safely at home. Hospice provides only limited hands-on help, and families must provide the remainder or hire aides.
The new report, which analyzed the records of more than 200,000 cancer patients, found that 24.7 percent died in hospitals in 2010. The rate was much higher – 43 percent – in Manhattan, and far lower – 12.2 percent – in Sarasota, Fla. Locally, most hospitals were near the national average, but Cooper University Hospital and Einstein Medical Center were at 32 percent.
Nationally, 62 percent of patients were hospitalized in the last month of life, and 28.8 percent were in the ICU. In this area, only Thomas Jefferson University Hospital had fewer cancer patients hospitalized in the last month than the national average. All were above the national average for ICU stays.
Goodman said that Johns Hopkins and Memorial Sloan-Kettering Cancer Center, both well respected, gave less intense care. Only 18 percent of cancer patients at Hopkins went to the ICU in the last month, and only 11.5 percent at Sloan-Kettering did so.
Rebecca Aslakson, an intensive-care and palliative-care doctor at Hopkins, said her hospital teaches doctors about the importance of palliative care, which emphasizes pain control and patient goals, and shows them how to have hard conversations with patients. The philosophy is that “care up until the moment a person dies should be reflective of who they are and what they value,” she said.
James Dwyer, chief clinical officer for Virtua Health, said Virtua Memorial Hospital, which had relatively low numbers, has had a strong relationship with Samaritan Hospice and an inpatient hospice unit. Samaritan is now partnering with the entire system.
At Abington Memorial Hospital, which is closer to the national average than most local hospitals, some patients go to the hospital because of a complication from their disease or treatment that can’t be managed at home, said Maurice Gross, director of palliative medicine. He thinks there would be “less use of futile care at the end of life” if people talked with palliative specialists earlier.
Susan Gregory, a palliative-care doctor and medical director of critical care at Lankenau Medical Center, said those conversations should start outside the hospital, where most cancer care occurs.
Still, she said, decisions about how to care for cancer patients do not follow a neat script.
“I know that every single number on this page is a person,” she said as she looked at the Dartmouth report.
Some patients have as much trouble admitting that death is imminent as their doctors do. Our culture says you “fight” cancer more successfully with a positive attitude.
Gregory recently had a patient who did not respond to chemotherapy and was approaching death.
“Doc, I’ve got too much to live for. I’m going to fight this,” he told her.
“We’re in a day-at-a-time situation,” she responded. “I want you to get the most you can out of each day, because we don’t know how many days there are going to be.”
She didn’t press the case and felt bad that they hadn’t had a more fruitful conversation.
“You start to feel like you’re kicking a puppy,” she said.