Although fewer Medicare patients with cancer died in the hospital in 2010 than in the years 2003–2007, aggressive treatment continues at the end of life, according to a new report from the Dartmouth Atlas Project.1 The findings also show that a significant number of patients were likely to receive life-sustaining treatments, including intubation, a feeding tube, or cardiopulmonary resuscitation, in the final month of life, or to undergo chemotherapy during the last 2 weeks of life.
The report examined trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute–designated cancer centers. It is the first Dartmouth Atlas report with a longitudinal analysis of the care provided to Medicare patients with advanced cancer.
According to the report, although the percentage of patients with cancer receiving hospice care during the last month of life has increased to 61.3% in 2010 from 54.6% in 2003–2007, the percentage of patients admitted to hospice care during the last 3 days of life—when it is often too late to provide much benefit—rose from 8.3% in 2003–2007 to 10.9% in 2010.
The report also found that most patients with cancer who are approaching the end of their lives prefer supportive care that minimizes symptoms and the number of days spent in the hospital. “Unfortunately, the care patients receive does not always reflect their own preferences, but the prevailing styles of treatment in the regions and health-care systems where they happen to receive cancer treatment,” wrote the authors.
Hospice Services Provided Too Late
In a statement, David C. Goodman, MD, MS, Professor of Pediatrics and Health Policy at The Dartmouth Institute for Health Policy & Clinical Practice and coprincipal investigator of the Dartmouth Atlas Project, said, “Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit. Fuller discussions with patients who have advanced cancer on their prognosis and options for care can lead to a better quality of life than many receive today.”
Communication on Care Goals
ASCO has been proactive in calling for an increase in physician-patient communication on treatment options and care goals immediately following a diagnosis of advanced cancer and published a provisional clinical opinion on palliative care in 2012.2
“ASCO has long advocated for improved physician-patient communication about care preferences, especially for patients with advanced cancer,” said ASCO President
Clifford A. Hudis, MD, FACP. “Over the past few years, we’ve seen data that show that patients who talk about these issues with their clinicians early in the course of treatment are more likely to receive the type of care they prefer. These important discussions lead to greater use of palliative and hospice care, and can improve a patient’s quality of life, sense of control, and satisfaction with their care and choices.”■
Disclosure: Drs. Goodman and Hudis reported no potential conflicts of interest.
1. Goodman DC, Morden NE, Chang C, et al: Trends in cancer care near the end of life. Lebanon, New Hampshire; The Dartmouth Insitute. September 4, 2013. Available at www.dartmouthatlas.org. Accessed October 8, 2013.
2. Smith TJ, Temin S, Alesi ER, et al: ASCO provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 30:880-887, 2012.