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Geography a key to cancer patients’ last days

Use of hospice, aggressive care varies by region

By Rob Stein
Washington Post / November 17, 2010

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WASHINGTON — The proportion of cancer patients who die in the hospital and get hospice care varies widely from region to region and hospital to hospital across the country, according to a new report.

Researchers at the Dartmouth Atlas Project in Lebanon, N.H., analyzed the records of 235,821 Medicare patients ages 65 and older who died between 2003 and 2007. Overall, the researchers found that one-third of patients spent their last days in hospitals and intensive-care units. But there was a big range. At one end was Manhattan, where 46.7 percent died in the hospital. In contrast, 7 percent of cancer patients died in the hospital in Mason City, Iowa.

While chemotherapy and other aggressive procedures can prolong life and enable some cancer patients to return home and to work, studies have shown that these treatments have little or no value for frail elderly patients and those with advanced cancer. But 6 percent of patients received chemotherapy in their last two weeks of life, and the rate was much higher — more than 10 percent — in some places, the researchers found.

Similarly, more than 18 percent of cancer patients were placed on a feeding tube or received cardiopulmonary resuscitation in their last two weeks of life in Manhattan, compared with less than 4 percent in Minneapolis.

Use of hospice care also varied a lot. In at least 50 academic medical centers, less than half of patients with a poor prognosis receive hospice services, the researchers found. And in some hospitals, patients were referred to hospice care so close to the day they died that it was unlikely to have provided much comfort.

David Goodman, who led the analysis, said the findings indicate that too many cancer patients are dying in the hospital and too few are getting adequate palliative and hospice care. Surveys have shown that 80 percent of patients would prefer to die at home, he noted. That suggests that doctors are treating cancer patients too aggressively and are often not honoring their wishes.

“The care that patients receive has less to do with what they want and more to do with the hospitals they happen to seek care from,’’ Goodman said during a briefing. “Geography is destiny.’’

This is important because about 500,000 Americans die from cancer each year, half of whom are 65 and older, Goodman said. This is hardly the first time that specialists have concluded that palliative and hospice care is underused. The National Academy of Sciences Institute of Medicine has addressed the issue several times.

The study did not examine the reasons for the big differences. But Goodman said that a lot of it probably has to do with individual variations among doctors and hospitals about their practices, with some being slower to embrace hospice care than others. In some cases it may be that some hospitals have more intensive care beds than others while others have more hospice and palliative care facilities. In addition, doctors are often reluctant to directly confront the fact that further treatment is futile.

Specialists on palliative and hospice care praised the report, saying it should encourage doctors to discuss end-of-life wishes with their patients earlier. But some said it remained unclear how often patients’ wishes were not being honored. R. Sean Morrison of the American Academy of Hospice and Palliative Medicine said there are many cultural and regional differences in peoples’ wishes. Some really want to die at home. Others really want to do whatever they can to live as long as they can. Some also feel safer dying in a hospital. But Morrison agreed that doctors need to do more to figure out what patients really want and make sure they die the kind of death they desire.

The issue of end-of-life counseling turned out to be an explosive part of the bitter debate over the federal legislation to overhaul the nation’s health-care system. Critics charged that the legislation would lead to “death panels’’ of government bureaucrats deciding who should get life-saving care.