Patients with advanced cancer who discuss end-of-life care with
their physicians appear to have lower health care costs in the final
week of life than those who do not, according to a report in the March
9 issue of Archives
of Internal Medicine.
A second report finds that black and Hispanic patients tend to have
higher health care costs at the end of life than white patients,
despite dying of similar causes. Two other articles in the same issue
examine dying patients' feelings of abandonment by physicians and
reasons that patients request physician aid in dying in Oregon.
A disproportionate share of medical costs occur at the end of life,
according to background information in the first article. Almost
one-third of Medicare expenditures are attributable to the 5 percent of
beneficiaries who die each year, and about one-third of expenses in the
last year of life are spent in the final month. Previous studies
suggest that most of these costs result from life-sustaining care,
including resuscitation and mechanical ventilation.
Baohui Zhang, M.S., of the Dana-Farber Cancer Institute, Boston, and
colleagues studied 603 patients who were part of the Coping With Cancer
study, funded by the National Institute of Mental Health and the
National Cancer Institute. At the beginning of the study - between 2002
and 2007 - 188 (31.2 percent) reported discussing their wishes about
end-of-life care with their physicians. They were then followed up
In the final week of life, patients who reported having end-of-life
discussions with their physicians had average aggregate health care
costs of $1,876, compared with $2,917 for patients who did not. Formal
and informal caregivers who were interviewed after patients' deaths
reported that those with higher costs also had a worse quality of death
in their final week.
In the second article about end-of-life costs, Amresh Hanchate,
Ph.D., of Boston University School of Medicine, and colleagues report
on an analysis of data from 158,780 Medicare beneficiaries who died in
2001. In the last six months of life, costs varied significantly by
racial and ethnic background costs for whites averaged $20,166,
compared with $26,704 for blacks and $31,702 for Hispanics.
"Although 40 percent to 60 percent of these excess differences are
associated with geography, i.e., living in high-medical-expenditure
areas, substantial differences remain, even after adjustment for many
patient characteristics in addition to geographic variables," the
authors write. "Strikingly higher rates of use of intensive end-of-life
treatments such as ICU [intensive care unit] and ventilators account
for most of these residual differences."
"Therefore, at life's end, minorities often receive more expensive
but not necessarily life-enhancing care," they conclude. "It is unclear
how much of this was actively sought, or the extent to which racial and
ethnic differences are principally driven by how choices are presented
or how they are 'heard.' These would be fruitful questions for future
(Arch Intern Med . 2009;169:480-488, 493-501.
Patients and Families Report Feeling Abandoned by Physicians
at the End of Life
Patients who are dying and their families report that feelings of
abandonment by their physicians at the end of life have two components:
a loss of continuity of care before death and a lack of closure near
death or afterward. In another article in the March 9 issue, Anthony L.
Back, M.D., of Fred Hutchinson Cancer Research Center and University of
Washington, Seattle, and colleagues identified 55 patients with
incurable cancer or advanced lung disease who were expected to live a
year or less. These patients, along with 31 physicians, 36 family
caregivers and 25 nurses involved in their care, were interviewed at
enrollment and again at four to six months and at 12 months.
"Early on, patients and family caregivers fear that their physician,
whose expertise and caring they have come to depend on, will become
unavailable," the authors write. "Physicians are aware of this fear and
attempt to address it with reassurance or continuity strategies. Yet,
as death approaches, some patients and families may feel abandoned
nonetheless because they lose the continuity of their physician's
expertise or their relationship with that physician."
"Near death or afterward, they may also experience a lack of closure
of that relationship. Most of these physicians are not consciously
aware of having abandoned their patients. Instead, they report lack of
closure or a feeling of unfinished business." The findings could help
physicians structure care to maintain the professional value of
non-abandonment, including use of non-hospice palliative care or
closure-promoting communication strategies involving nurses and other
members of the health care team.
(Arch Intern Med . 2009;169:474-479.
Oregonians Interested in Physician Aid in Dying Appear
Motivated by Fear of Future Events
Individuals exploring physician aid in dying in Oregon appear to be
motivated by worries about future pain and loss of autonomy rather than
current symptoms, according to another report in the same issue. Linda
Ganzini, M.D., M.P.H., and colleagues at Portland Veterans' Affairs
Medical Center and Oregon Health and Science University, Portland,
surveyed 56 individuals who either requested physician aid in dying or
contacted a related advocacy organization. Participants were asked to
rate the importance of 29 reasons for seeking this option on a scale of
one (least important) to five (most important).
The most important reasons - with median (midpoint) scores of five -
were wanting to die at home and control the surrounding circumstances
of death; loss of independence; and concerns about future pain, poor
quality of life and inability to care for one's self. All current
physical symptoms were rated as unimportant (one).
"Our data suggest that when patients first request physician aid in
dying, they do so not because of physical symptoms or quality of life
at the time of the request but in anticipation of future suffering that
they perceive as intolerable. Their desire to die is not strong, and
they do not believe that their life is poor in quality, meaningless or
worthless. Rather, they appear to be protecting against the risk of
future experience they do not believe they can endure," the authors
write. "When confronted with a request for physician aid in dying,
health care providers should first work to bolster the patient's sense
of control and to educate and reassure the patient regarding management
of future symptoms."
(Arch Intern Med . 2009;169:489-492.