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Cancer patients too often die in hospitals, study says

By Rob Stein

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, only 7 percent of cancer patients died in the hospital in Mason City, Iowa. Washington fell right about in the middle, with about a third of patients dying in the hospital.

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.

A doctor holds a patient's hands at a care center in Dublin, Ohio. The doctor provides end-of-life care to patients with cancer. (By Chris Russell/Associated Press)

Similarly, more than 18 percent of cancer patients were placed on a feeding tube or received CPR 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 hospital, patients were referred to hospice care so close to they 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 experts have concluded that palliative and hospice care is underused. The National Academy of Sciences Institute of Medicine has addressed this 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.

Experts 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 lots of 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 agrees 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. In fact, the legislation called for Medicare to reimburse doctors to confer with patients about their end-of-life wishes and how to ensure those preferences are followed. The consultations would have been voluntary. The measure was not included in final legislation.

By Rob Stein  | November 16, 2010; 11:00 AM ET
Categories:  Cancer, Hospitals, death and dying, end-of-life care, palliative and hospice care  
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The conclusions you draw from this survey are not based on the survey. You don't know that the doctors are ignoring the patients directives, you made that up. Many times when I or friends I know through treatment are faced with our deaths being imminent, WE change our minds about leaving the hospital. No doctor ignores us, we decide to fight our cancers aggressively. And sometimes my friends who have written orders not to be left to die in a hospital actually have died in the hospital by their own choice, they made the decision to change their mind, not a doctor. I too would rather not die in a hospital but I have come close to doing so twice in the last five years because my good doctor has brought to my attention a treatment that might help me that we haven't tried. And I decided to take that risk that I might die in a hospital even though every document I have states otherwise, I choose to take the risk myself. Since the survey doesn't address who makes the decision to stay in the hospital or aggressively treat the cancer, your entire blog post here is garbage. All you are doing is whipping up anti-doctor hysteria. Stop it. You are just making it harder for us cancer patients and our doctors.

Posted by: greenmansf | November 16, 2010 12:34 PM | Report abuse

My comment does not concern cancer patients per se, but end of life care. I have been witness to 3 close family members who passed away within the last few years and one who just entered hospice care last week. In my case, due to the patients condition, the family ended up being responsible for making the end of life decisions. In one case, I asked the doctor to initiate hospice care. Thankfully, all the doctors involved were honest and forthright in dealing with the family. Even though we all knew our relatives preferences for end of life care, it was still difficult to give up hope. My whole point is that the study mentions doctors consulting with patients, I should hope that when patients are incapable that doctors also include family members.

Posted by: qonder | November 16, 2010 12:43 PM | Report abuse

Well, let's just kick those frail old cancer patients out of their hospital beds and save a few bucks huh? Sounds like the start of death panels to me.

Posted by: thebink | November 16, 2010 1:06 PM | Report abuse

Bink: It has nothing to do with saving money. End of life counseling is a very good thing and SHOULD be offered to everyone especially the old and terminally ill. Maybe you'll be in a crash someday and are in a comatose brain dead state. Will you family be forced to watch you sit there like a plant forever? Or will you have an end of life directive?

Posted by: echoparkla | November 16, 2010 1:21 PM | Report abuse

From the LA Times coverage of this story:

"Goodman, who is also director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said researchers were not "looking to control costs on the backs of people with advanced cancer," or to penalize hospitals that pursue aggressive treatment. Rather, he said their goal was to promote palliative care, which aims to minimize a patient's suffering and allow for the best possible quality of life."

This "study" is a sham. Any time one conducts a study with a specific goal for an outcome, it is not science. It is propaganda.

Posted by: FutureView2010 | November 16, 2010 1:33 PM | Report abuse

Get a directive to physicians and a health care power of attorney to make your end of life intentions clear to your doctor(s) and to your family, spouse, etc. As at attorney I have written thousands of these documents for military members and all were voluntary. In addition, I would recommend you have a Do Not Resuscitate Order in your medical records. As a cancer survivor and patient, I have appointed my own "death panel" comprised of my spouse, daughter and doctors. I would recommend anyone with a chronic and potentially life threatening condition strongly consider doing the same.

Posted by: elawjag1 | November 16, 2010 2:35 PM | Report abuse

The USA currently spends about 30% of the health care dollar on medical futility for those past all cures, all remissions, all reprieves from advanced age or dementia. In many estimations in the literature, that's about 1.2 trillion USD per annum spent foolishly on those who are past all benefit. Most will pursue a wrong-headed cure orientation when the inevitable is in the cards based on weight loss,changing CBC, lowering albumin & pre-albumin levels, rising CRP and the provider's knowledge & experience with terminal & deleterious disease processes. Most astute providers know that death will arrive within 6 months, yet many people are sold many goods & services deemed by many as medically futile. The ICU, the hospital, more treatments, more diagnostics, labs and medicines are the only places to make money these days. ICU per day costs about $10,000 for bed & nursing charge. The myriad consultants begin ordering all sort of futile treatments, intubation, labs, disposibles, diagnostics etc in a feeding frenzy which may cost between $500,000- $1 million USD before death rescues that poor unfortunate from the ICU chamber of horrors. Believe me, I was that critical care registered nurse for 9 years! Hospice typically costs between $100-450 per day at home where the quality of life is measured, not by the number of days, but the life in one's days. The patient has dignity & real hope to spend his remaining months & weeks at home, with family, pursuing his bliss & being comfortable until he passes away. There are no honest medical goals to achieve pursuing a cure orientation aggressively, in fact it is pure hell & mendacity.The only achievable medical goals for this subset of people, which are accomplished on hospice, are relief from symptoms and education & advice about diagnoses. There are many obstacles to sane end of life care: an entitlement mentality, family members who depend on the income of the loved one, the great American medical business machine, fear of lawsuits, the stigma of decline, death & dying. The fee-for-service scheme also encourages a mendacious waste of resources, especially around the dying. Most people have no notion of what actually occurs in the ICU, with a real code blue & what life may look like on a life support machine. For a person who has less than six months to live, these horrors are endured daily in the nation's ICUs: intubation, suctioning, turning, restraints, paralysis, tubes in every orifice & a large endotracheal tube from mouth to lungs. It is insane! Please visit my web pages about sane choices at end of life:

and view this PBS special on Frontline "Facing Death" about medical futility:

Sincerely, Damiano de Sano Iocovozzi MSN FNP CNS at the Thomas Edwin Walls Foundation

Posted by: Damiano | November 16, 2010 4:13 PM | Report abuse

These generalizations about regional behavior seem absurd. People travel from places like Mason City, Iowa, to places like Manhattan for treatment, particularly when their cancers aren't responding at their local hospitals. When my dad in Florida had cancer, he went to Sloan Kettering.

Posted by: Itzajob | November 17, 2010 11:29 AM | Report abuse

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