America’s hospitals treat patients with life-ending cancers very differently in their final months, with some deploying chemotherapy and other life-prolonging efforts until the end and others directing most of their patients into hospice, a new study finds.
The report released today by the Dartmouth Atlas of Health Care argues that many patients are getting aggressive care that might not be best for them. It also adds to the drain on Medicare’s pocketbook — a point the report doesn't address.
More than half of Medicare recipients getting treatment at Westchester Medical Center in Valhalla, N.Y. (57.3 percent) ended up dying in the hospital, according to the report. Only 18.7 percent of cancer patients who got care at Evanston Northwestern Healthcare in Evanston, Ill., ended up dying in the hospital.
Dartmouth surmises the differences are due to physicans in some hospitals favoring more aggressive treatments, while others are more amenable to hospice, which is often delivered at home and is championed in the report as a more humane way to die (as well as less expensive for Medicare).
At Monmouth Medical Center in Long Branch, N.J., 73 percent of patients used hospice in their final month, while at Westchester Medical, 18.6 percent did. (Westchester Medical didn’t respond to a request for comment.)
Dartmouth researchers argue that if more patients understood their choices about dying, more would choose hospice. "Unfortunately the care that patients get is much more about where they happen to be treated rather than care that follows their preferences," says Dr. David Goodman, the lead author of the study, issued by the Dartmouth Institute for Health Policy & Clinical Practice, based in Hanover, N.H.
The report looked at Medicare records for more than 235,000 patients with cancer who died between 2003 and 2007.
Dartmouth’s previous end-of-life studies have had detractors. Some hospitals argue that they provide more aggressive treatments to prolong life.
Others say Dartmouth's 20/20 hindsight isn't fair, because imminent death is not as obvious when a patient is still breathing as it may seem retrospectively. Dartmouth says it only studied cancers that had particularly poor prognoses or were in a very advanced stage, so that the likelihood of death was strong.
Whatever the reasons, the New York City area stands out in the study. A hospital death was particularly likely in Manhattan and some of the surrounding hospital markets, occurring for more than 4 of every 10 Medicare recipients with cancers likely to be terminal.
In a sign that doctors weren't letting patients go without a fight, nearly 1 in 5 Medicare recipients in Manhattan received in their final weeks of life several types of treatment Dartmouth described as "aggressive," including the insertion of a feeding tube or CPR.
Mason City, Iowa, is the place where Medicare recipients were least likely place to die in a hospital. Only 7 percent expired as inpatients, Dartmouth found.
But Mason City's practices may reflect the kind of place it is, rather than hospital or doctor practices. Dr. Douglas Blayney, a professor at Stanford University School of Medicine and past president of the American Society of Clinical Oncology who thinks the Dartmouth report is valuable, notes that in order for patients to get hospice, they need a relative, neighbor or friend to help care for them. That's less likely at places with large portions of poorer patients, and more likely in smaller, rural areas such as Mason City, Blayney says.
“In general, places where there are strong support networks have better acceptance and utilization of home care and hospice,” he says.