‘Geography is destiny’ for end-of-life care, which often is costly, aggressive
Where a terminally ill cancer patient spends his last days largely depends on where he lives and what hospital he’s being treated at. A study released last week shows little evidence that advanced cancer treatment aligns with a patient’s wishes. “As many as 80% of patients at the end of life strongly want to be in a more homelike setting,” says David Goodman, left, of the Dartmouth Atlas of Health Care.
For patients with advanced cancer who are nearing the end of life, the likelihood that they will spend their final days in a costly hospital intensive-care unit or at home depends largely on where they live and the hospital at which they seek care.
In other words, geography is destiny, according to David Goodman, professor of pediatrics and health policy at Dartmouth Medical School, Hanover, N.H., and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.
Goodman also is the co-principal investigator of the Dartmouth Atlas of Health Care, a long-running project that uses Medicare data to examine variations in the way healthcare is provided across the country.
And in its first report on the quality of endof-life cancer care for Medicare beneficiaries, released Nov. 16, Dartmouth Atlas researchers found little evidence that treatments are aligned with patients’ wishes.
The majority of cancer patients would much prefer to receive end-of-life care that allows for the highest quality of life and that enables them to live comfortably, without pain, supported by palliative or hospice care, said Goodman, the report’s lead author. “That does not mean all patients want that, but on average, as many as 80% of patients at the end of life strongly want to be in a more homelike setting,” he said.
But far from reflecting those preferences, the report—which examined data from 235,821 Medicare patients with advanced cancer who died between 2003 and 2007—found significant variations in end-of-life care from region to region and from hospital to hospital. Roughly 29% of advanced-stage cancer patients across the country died in a hospital during the threeyear period, and that number reached as high as 46.7% in the borough of Manhattan in New York City and 41.1% in Newark, N.J.
That contrasts sharply with Cincinnati, Ohio, and Fort Lauderdale, Fla., which had rates of 17.8% and 19.6%, respectively. And in Mason City, Iowa, the rate of in-hospital cancer deaths was only 7%.
The disparities persisted across other measures as well, including intensive-care admissions and chemotherapy administered during the last two weeks of life. About 70% of cancer patients in Detroit were hospitalized at least once during their last month of life, compared with 46.3% in San Angelo, Texas, according to the report. And cancer patients were far less likely to receive life-sustaining treatments such as endotracheal intubation or CPR in the last month of life if they lived in Minneapolis
Zook says Mercy Medical Center-North Iowa makes decisions based on patients’ goals.