Care for dying patients may sometimes be too aggressive

Experts say recent studies underscore the need to re-evaluate how end-of-life care is handled.

By Kevin B. O'Reilly, amednews staff. Aug. 7, 2006.

Two recent studies of Medicare data suggest that medical interventions for terminally ill cancer patients and chronically ill patients at the end of life are sometimes overly aggressive and wasteful. Experts said the findings demonstrate that changing how end-of-life care is approached remains a challenge.

"These studies reinforce the point that oftentimes aggressive care at the end of life ... is still an issue," said John G. Carney, vice president of aging and end of life at the Center for Practical Bioethics in Kansas City, Mo. "This needs to be looked at from various perspectives, not just oncology."

Caring to the end
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The first study, a May online report from the Dartmouth Medical School's Center for the Evaluative Clinical Sciences, examined records of 4.7 million chronically ill Medicare enrollees who died between 2000 and 2003 and found huge variations in the volume and intensity of end-of-life care provided without accompanying quality gains.

Most telling, said the Dartmouth researchers, was that the average number of hospitalized days during the last six months of life ranged from 12.9 days per patient at the Mayo Clinic's St. Mary's Hospital to 23.9 at New York-Presbyterian Hospital. Patients who spent more time in the hospital, in intensive care units or seeing specialists did not get better results, according to the report.

The variation and attendant waste -- an estimated $40 billion over four years -- was partly a result of "falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can't be cured," principal investigator John E. Wennberg, MD, MPH, said in a statement.

The second study, a June presentation at the American Society of Clinical Oncology's annual meeting, found that chemotherapy and intensive hospital treatment increased in the last two weeks of life during the 1990s; the most recent Medicare data available are from 1999.

More patients were sent to hospice in the 1990s, but a greater percentage of cancer patients were sent there in the last three days of their lives. That means more people were sent to hospice "to die, as opposed to getting the full benefit of hospice care and spending time controlling symptoms," said Craig C. Earle, MD, the principal investigator and an oncologist at the Dana-Farber Cancer Institute.

A cancer patient's receiving aggressive treatment shortly before dying is not necessarily an instance of poor quality, but cumulative data may reveal an opportunity for quality improvement, Dr. Earle said.

"If you're an outlier compared to other oncologists, and half of your patients are getting chemo in the last two weeks of life, maybe you need to look at why that is," he said. "Maybe you're not having the difficult conversations with patients about end of life. Sometimes it's easier just to say, 'Well, let's try this next chemotherapy drug.' "

Carney said that as more elderly patients have comorbidities and die after long chronic illnesses, ambiguity in recommendations of care will drive patients to opt for aggressive treatments, though the cause for optimism may be small.

"This isn't all on the doctors' shoulders," Carney said. "This is patients driving this too."

ADDITIONAL INFORMATION:

Caring to the end

Though the importance of palliative care became more accepted in the 1990s, the percentage of Medicare cancer patients who received aggressive treatments at the end of life increased slightly during the decade.

End-of-life treatment	1993	1999
Admitted to hospital in last month of life	8%	11%
Received chemotherapy in last two weeks of life	10%	12%
Entered hospice in last three days of life	12%	15%

Source: "Consistency in Regional Trends of Aggressiveness in Cancer Care Near the End of Life for Elderly Americans, 1991-2000," presented by Craig C. Earle, MD, at the American Society of Clinical Oncology annual meeting, June.