End-of-Life Choice, Palliative Care and Counseling

‘We should be better judges of when things are futile.’by Jay

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By Sarah Kliff
The Washington Post
April 10, 2012

Last week, a new initiative called Choosing Wisely got a lot of positive attention for gathering nine medical specialty groups and coming up with 45 procedures that even doctors think doctors shouldn’t do. But a new study on end-of-life care suggests that actually implementing those recommendations will be difficult.

Researchers at the Dartmouth Atlas looked at how well cancer treatment facilities, from world-renowned institutions to community hospitals, did at following end-of-life care guidelines. The guidelines were drawn up by the National Quality Forum, in consultation with stakeholder groups, and include avoiding chemotherapy treatment in the last two weeks of life and reducing intensive care unit admissions. The new parameters were largely meant to respond to numerous studies showing that, at the end of life, cancer patients tend to want less aggressive treatment.

So these are, in other words, treatments that patients don’t think doctors should do. But they get done anyway.

Dartmouth’s Nancy Morden thought that specialized cancer centers – the places that have developed international reputations for the care they provide – would better adhere with these metrics. These were, after all, places that focused exclusively on providing the highest quality oncology.

Except, they didn’t. Morden has a study in this month’s Health Affairs which finds that 23 percent of patients at national cancer centers visited the ICU in the last month of life. That figure stood at 24 percent among community hospitals. Looking across all treatment settings, one in 10 patients received a chemotherapy treatment in their last two weeks of life. Forty-eight percent saw 10 or more physicians in their last six months of life.

“Physicians are not perfect but we do have a lot of experience with death,” says Morden. “We should be better judges of when things are futile. And our job, then, is to be informing patients.”

What troubles Morden most about her findings is that it doesn’t line up with the body of research on patient preferences, which shows that a majority of patients prefer comfort over curative care and would rather die at home than in the hospital.

“I think people don’t understand the difference between rationing, and between quality of care at the end of life,” says Morden. “We’ve not done a good job of having that discussion. People equate hospice to giving up inappropriately when, sometimes, it’s the decision the patient wants.”

Morden thinks that the health care system’s financial incentives may also play a role. She found that at community health centers, where doctors are more likely to be paid based on the volume of medicine they provide, tended to have higher rates of chemotherapy treatment in the last 14 days of life.

“We know that oncology practices earn more than half of their budgets by selling chemotherapy drugs,” says Morden. “If it’s delivering chemotherapy, the incentives are aligned in a way that would encourage additional care.”

Morden doesn’t suggest that hospitals should be at a point where no cancer patients get chemotherapy treatment in the last two weeks of life. “We’re not saying that we should get to zero percent of cancer patients dying in hospitals,” she says, “But we should be getting a lot lower than 30 percent.” Treatment guidelines, three years in, have not gotten much traction moving end-of-life cancer care in that direction