Many Medicare cancer patients with poor prognoses are receiving overly aggressive and expensive inpatient procedures in the last month of life, including chemotherapy, intensive care, intubation, and feeding tubes, despite not much evidence that at that point, it will do any good.
That's the conclusion in the latest report from the Dartmouth Atlas Project, which says that quality of end-of-life cancer care and use of hospice and palliative care services in a cancer patient's last month of life are enormously variable, depending on the hospital referral region and the specific hospital or health system where the patient sought care.
"This is a time period where the use of chemotherapy is generally considered to be futile. Yet in some regions and medical centers, the rate (in which chemotherapy was administered to patients with only weeks to live was as high as 10%," David Goodman, MD, lead author and co-principal investigator of the report, said at a news conference Tuesday.
Barriers to more appropriate use of palliative care and hospice services for patients who are clearly dying include "unfavorable payment (to hospitals and doctors) compared to the alternative, which we're calling curative care, including chemotherapy, which is more richly reimbursed," said Goodman, who also is the director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.
The report examines records of 235,821 Medicare patients 65 or older who had aggressive or metastatic cancer and who died between 2003 and 2007. The data was segregated by more than 400 hospital referral regions, and by nearly 140 specific academic medical centers with at least 80 Medicare cancer deaths a year.
Goodman described "a sort of a cultural norm in oncology, and of physicians in general, to press on with efforts to extend life, even when that's not possible."
"Doctors and health systems need to take a look at themselves," he said. "They need to examine where they need to make their investments, and to make sure that they're fairly investing in what I think is one of the most undertreated (services) that we have in Medicare today, and that is undertreatment with palliative care and hospices services for those with advanced disease."
And, he said, they need to be more honest with their patients, and provide realistic expectations about their chances for cure at this late stage of their disease.
"We as physicians often make assumptions about what patients and families want for their lives. We tend to be really uncomfortable about sharing news that a cure is unlikely."
He's aware that "Some physicians will describe this as taking away hope. That's language that I think has caused a lot of harm in cancer care. What patients really want is for physicians to be honest with them about their chances for cancer remission, but also honest about their chances for disease progression."
The report revealed huge variation in utilization of aggressive types of care in the last month of life for patients dying of certain types of cancers known for their poor long-term survival, such as leukemia and lymphoma, and cancers of the colon and pancreas and lung.
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In many cases, Goodman says, studies have shown that so-called curative care in this population is often "not curative at all" nor does it prolong life.
"There were some instances where patients actually live longer wit hospice care." That, he said illustrates the importance of funding and organizing high quality comparative effectiveness research, because such studies just may find results "that really turn the world upside down in terms of our assumptions.
"You have a patient who is not doing well with the disease, who is debilitated—these patients are very sick, anemic, with abnormalities in white blood cells. They have to spend time in the hospital and the ICU; they are more likely to have IVs and feeding tubes, and all these with the chance of infection. And now we're giving them chemotherapy."
Nancy Foster, vice president for quality and patient safety with the American Hospital Association, said studies like the Dartmouth Atlas Project's "help shine a light on the importance of end-of-life care." Unfortunately, she said, "hospice care is not readily available in all parts of the United States.
The delivery of hospice care requires both trained palliative care physicians and a hospice organization, and, as noted on the Center to Advance Palliative Care, there are both too few trained clinicians and too few hospice organizations to meet the need for hospice care." She says public policy needs to be changed.
The National Hospice and Palliative Care Organization applauded the report but said it was not necessarily a surprise. "One of the key messages that I take away from this report is the critical need for hospitals and all healthcare professionals to ensure that all patients are informed earlier about the course of an illness and the range of options available—options that include hospice and palliative care," said J. Donald Schumacher, NHPCO president and CEO.