Many Medicare cancer patients with poor prognoses are receiving overly aggressive and expensive inpatient procedures in the last month of life, including chemotherapy, intensive care, intubation, and feeding tubes, despite not much evidence that at that point, it will do any good.
That's the conclusion in the latest report from the Dartmouth Atlas Project, which says that quality of end-of-life cancer care and use of hospice and palliative care services in a cancer patient's last month of life are enormously variable, depending on the hospital referral region and the specific hospital or health system where the patient sought care.
"This is a time period where the use of chemotherapy is generally considered to be futile. Yet in some regions and medical centers, the rate (in which chemotherapy was administered to patients with only weeks to live was as high as 10%," David Goodman, MD, lead author and co-principal investigator of the report, said at a news conference Tuesday.
Barriers to more appropriate use of palliative care and hospice services for patients who are clearly dying include "unfavorable payment (to hospitals and doctors) compared to the alternative, which we're calling curative care, including chemotherapy, which is more richly reimbursed," said Goodman, who also is the director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.
The report examines records of 235,821 Medicare patients 65 or older who had aggressive or metastatic cancer and who died between 2003 and 2007. The data was segregated by more than 400 hospital referral regions, and by nearly 140 specific academic medical centers with at least 80 Medicare cancer deaths a year.
Goodman described "a sort of a cultural norm in oncology, and of physicians in general, to press on with efforts to extend life, even when that's not possible."
"Doctors and health systems need to take a look at themselves," he said. "They need to examine where they need to make their investments, and to make sure that they're fairly investing in what I think is one of the most undertreated (services) that we have in Medicare today, and that is undertreatment with palliative care and hospices services for those with advanced disease."
And, he said, they need to be more honest with their patients, and provide realistic expectations about their chances for cure at this late stage of their disease.