End-of-life cancer care, whether decided by doctor or patient, favors intensive treatment that may be shortchanging a person’s chance of greater comfort in their dying days, Dartmouth College researchers said.
Too many advanced-cancer patients receive invasive hospital treatments such as feeding tubes while they are dying instead of being directed to hospice and other palliative care that could ease suffering, the Dartmouth Atlas Project said today in a report. The group looked at data for Medicare, the U.S. health plan for the elderly, that showed an increase in cancer patients in intensive care units in the last month of life.
The share of cancer patients receiving hospice care has increased to about 61 percent in 2010 from 55 percent in 2003-2007, according to the report. That improvement obscures a more telling statistic: those admitted to hospice in the last three days of life -- when it’s too late to provide much comfort -- rose 31 percent, said David Goodman, co-principal investigator for Dartmouth Atlas.
“We’re seeing some pretty rapid changes in patterns of care but the move toward the care that most patients prefer is happening very unevenly, at the same time that many patients are receiving more aggressive in-patient care and less effective hospice care,” Goodman said in a telephone interview.
End-of-life cancer care varies widely across the nation, with large differences in the use of intensive care versus palliative care depending on where patients live, the Dartmouth study found. In Manhattan, for example, 43 percent of Medicare patients with cancer died in a hospital, compared with about 11 percent in Mason City, Iowa.
Patients with cancer whose illnesses advance despite treatment and find themselves with waning strength and energy should “be cautious about excessive medical care,” Ira Byock, a former director of palliative care at Dartmouth-Hitchcock Medical Center, said in an essay accompanying the study.
“Under the influence of the more-is-better mentality, well-intentioned clinicians and loving families can inadvertently cause people to spend precious, fleeting days at the end of a long illness in hospitals and ICUs, instead of at home or other places they would rather be,” he wrote.
Medicare policy, which requires patients to forgo curative care if they enter hospice, may discourage palliative care, Goodman said. Patients can and should seek palliative care, which is not the same as hospice, even while they’re undergoing treatments aimed at curing their cancer, he said.
“Palliative care in particular has lots of advantages when it’s introduced concurrently with efforts to prolong a patient’s life,” Goodman said. “If it looks like a patient is likely to pass away in weeks or months, it makes sense to have a wider range of options and transitions, and not what is often felt as a black-and-white situation.”
The study examined care in the last six months of life for more than 212,000 Medicare patients. Dartmouth Atlas studies variations in health-care spending and practices across the U.S.
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