At the end of life, clinicians should engage their patients in conversations about care plans that include addressing the cost of care, researchers say.
Patients with terminal cancer are not recommended to receive intensive medical services at the end of life, but more than half are receiving these services, a recently published journal article says.
In the last year of life, patients experience a disproportionate share of medical spending. Although much of this spending is associated with the costs of serious illness, clinicians can often predict when costly intensive medical services have low value for patients at the end of life.
Spending on intensive medical services at the end of life can have an adverse financial impact on patients and their families, according to the co-authors of the recent journal article, which was published in the Journal of the American Medical Association.
"Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families," the co-authors wrote.
There also are negative consequences for patient care, they wrote. "Intensive services at the end of life are not linked to better outcomes, are associated with poorer patient quality of life, and are considered undesirable by many patients."
Medical service costs at end of life
The researchers examined data for more than 48,000 patients over the age of 65 who died as the result of a solid tumor. The study generated several key data points:
- Despite recommendations from the National Academy of Medicine and the American Society of Clinical Oncology against intensive services at the end of life for this class of patients, 58.9% of them received intensive services in the last month of life
- Patients who received no intensive services in the last month of life generated $7,660 in mean health system costs
- Patients who received one or more intensive services in the last month of life generated $23,612 in mean health system costs
- Patients who received no intensive services in the last month of life generated $133 in mean expected beneficiary costs
- Patients who received one or more intensive services in the last month of life generated $1,257 in mean expected beneficiary costs
- An intensive care unit stay was the most expensive intensive service at more than $20,000 in health system costs per patient and more than $1,100 in expected beneficiary costs
- Chemotherapy was the least expensive intensive service at more than $2,900 in health system costs per patient and more than $800 in expected beneficiary costs
Patients and their clinicians should engage in shared decision-making about intensive medical services at the end of life, the JAMA researchers wrote.
"Ideally, patient-clinician decisions to pursue medically intensive services should involve discussions of the likelihood of benefit, risks, and side effects, including potential financial consequences, of these interventions. The present study provides reference cost estimates that may help inform those discussions."
The out-of-pocket costs of intensive services at the end of life are significant, they wrote.
"The present analysis indicates that patients experience approximately $1,250 out-of-pocket health costs in the last month of life due to medically intensive services. To place this number in context, the median annual household income of a Medicare beneficiary in 2014, the last year of this analysis, was $24,150, or $2,013 a month. Using these figures, expected beneficiary spending on medical services that have a low likelihood of helping them and could harm them may represent 62% of the household income of the typical Medicare enrollee in the last month of his life."
Avoiding questionable intensive medical services
In comments provided to HealthLeaders via email, two of the study's co-authors said intensive services at the end of life are often ill-advised.
"We found that most older cancer patients do indeed get intensive services at the end of life, even though experts recommend avoiding them. Other studies have shown that when asked, many patients prefer to avoid them as well," said Risha Gidwani-Marszowski, DrPH, a health economist at VA Palo Alto Health Care System in Menlo Park, California, and Steven Asch, MD, MPH, professor of medicine, Division of Primary Care and Population Health, Stanford University, Stanford, California.
"One guiding principal recommended by many specialty groups is having the discussions earlier in the course of the eventually fatal disease. This maximizes the chances of matching the course of care with the patients' preferences," they said.
When discussing end-of-life care with patients, the financial element should be part of the conversation, Gidwani-Marszowski and Asch said.
"Honest and early discussion with the patient about the medical risks and benefits of intensive care—and even an exploration of financial copays and burdens—can help patients make the best decisions. Other researchers have found that such discussions usually reduce patients' desires for intensive care. For patients with advanced cancer whose primary concern is longevity, still other researchers have found that less intensive palliative care that includes such discussion does not reduce life expectancy."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Clinicians can often predict when costly intensive medical services have low value for patients at the end of life.
Experts say most terminally ill cancer patients should not receive intensive medical services at the end of life.
In a recently published study, 58.9% of terminally ill cancer patients received intensive services such as ICU care in the last month of life.