Study examines end-of-life care for cancer patients

Many in their final days receive costly, aggressive treatments they may not want, according to researchers at the Dartmouth Atlas of Health Care. In California, Los Angeles County had the highest percentage of patients dying in hospitals.

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 250,000 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 41%, followed by Orange County (35%), Ventura County (32%) and San Bernardino County (28%).

“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.”

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 it was 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.

Susan Negreen, executive director of the Sacramento-based California Hospice and Palliative Care Assn., said the report underscores the need for increased 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 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. It’s a very difficult situation in a country where the technology is there, the latest and greatest of everything.”

The report also contrasted medical interventions at big-city hospitals to facilities located in mid-sized or small cities, often in the Midwest. Cancer patients were more likely to receive “aggressive life-sustaining treatment” — including feeding and breathing tubes and CPR — during the last weeks of their lives in Manhattan, (18.2%), Los Angeles (17.5%), Orange County, Calif. (16.7%) and Chicago (16.2%) compared with Minneapolis (3.9%), Des Moines (5.1%) and Seattle (6.4%).

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, that rate exceeded 10%.

Dartmouth Atlas researchers have drawn criticism in the past for failing to account for regional differences in patient health and the cost of providing care. Critics also say the researchers focus on the cost of hospital care instead of other measures of hospital quality — such as lives saved or extended.

Goodman, who is also director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said researchers were not “looking to control costs on the backs of people with advanced cancer,” or to penalize hospitals that pursue aggressive treatment. Rather, he said their goal was to promote palliative care, which aims to minimize a patient’s suffering and allow for the best possible quality of life.

Goodman said hospitals have expanded palliative care in recent years — including some urban hospitals such as Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore and Memorial Sloan-Kettering Cancer Center in New York City.

But he said government and private insurers still do not cover palliative care as comprehensively as they do hospitalization and may not pay for both simultaneously. Medicare covers hospice services but requires patients who choose that option to then forgo most hospital treatment.

The report does not say whether patients who opted for hospital rather than hospice care lived longer, although it cites other studies that found they did not. Federal officials are offering three-year grants to 15 hospice programs nationwide to serve patients without requiring them to give up hospital treatment.

“The paradigm that we’ve lived with for a long time of care versus cure needs to be reassessed,” Goodman said. “It’s led to tremendous suffering by patients and their families.”

At Ronald Reagan UCLA Medical Center, Dr. Tom Rosenthal said such studies are worthwhile.

“This issue of what’s appropriate care at end of life is such an important issue and really warrants the kind of detailed analysis this study provides,” said Rosenthal, chief medical officer for the UCLA Health System. “There really are nationally no norms for end-of-life treatment.”

But he cautioned that patients may have different needs.

“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,” he said, noting that the UCLA facility serves patients who come from a wide area to seek care.

The report showed that about 39% of advanced cancer patients treated at the Westwood hospital died there and about 48% were referred to hospice during the final month of life. At nearby Cedars-Sinai Medical Center, about 52% of similar patients died at the hospital, and about 34% were referred to hospice during their last month.

Rosenthal, who lost his mother to cancer in recent years, said he knows some doctors can be unrealistically aggressive.

“Her oncologist literally up to the time she was lying in a hospital bed was arguing for another round of chemotherapy,” he said. “We had to finally say ‘Look, no, stop.’”

The five UC hospitals recently joined with Cedars-Sinai 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, $10-million federal grant.

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