Where patients live in U.S. may decide where they die, new study says

WASHINGTON — One third of U.S. patients dying of cancer end up getting costly but futile treatment in hospitals, when hospice care to ease their suffering would be more appropriate, researchers reported on Tuesday.

The Dartmouth Atlas, a project that studies and documents variations in medical care across the United States, also found that where cancer patients live may decide the way they die: in an emergency room or at home.

The latest study finds that 29 percent of patients with advanced cancer died in a hospital between 2003 and 2007.

Last-ditch treatment of dying patients is expensive, upsetting to families and adds to suffering in many cases, cancer experts agree. They get feeding and breathing tubes and are often resuscitated repeatedly.

“Patients often unnecessarily receive care in the ICU and invasive procedures,” said Dr. John Goodman who coauthored the Dartmouth Atlas study of 235,821 patients with federal Medicare health insurance who died of cancer between 2003 and 2007.

“On average, patients … would much prefer to receive care that allows them the highest quality of life in their last weeks and months and care that allows them whenever possible to be at home and with their families,” Goodman told reporters in a telephone briefing.

The report, available at http://www.dartmouthatlas.org, shows a lack of planning about how to treat fatal cancer, which is the second leading cause of death in developed countries and will kill more than 500,000 Americans this year.

The study found that cancer care at the end of life varies markedly from region to region and from hospital to hospital.

“I think that the care patients receive has less to do with what they want and more to do with the hospital they happen to seek care from,” Goodman said.

‘Geography is destiny’
“In some healthcare systems, patients with advanced cancer have a greater chance of spending their last weeks and months in hospitals,” he added. “Geography is destiny.”

New York’s borough of Manhattan had the most cancer deaths in-hospital — 46.7 percent, compared with Mason City, Iowa, where 7 percent of cancer patients died in the hospital.

The issue affects the bottom line. The United States spent $2.3 trillion on healthcare in 2008 — $7,681 per resident, accounting for 16 percent of gross domestic product or GDP. Studies have shown about 31 percent of this — by far the biggest single share — is spent in hospitals.

President Barack Obama’s signature program, healthcare reform, is under fire from Republicans about to take control of the House of Representatives who say it does not do enough to control costs, as well as by left-wing Democrats who say it did not go far enough but who also want to control costs.

The American Society of Clinical Oncology, which groups and guides cancer specialists, supports palliative or hospice care for dying cancer patients, which eases pain and often allows patients to spend their last days or weeks at home.

In September, researchers reported that cancer patients who die at home do so more peacefully and at least one study has shown that dying cancer patients actually live a little longer on average if chemotherapy and other lifesaving measures are replaced with pain relief.

Doctors are often poor at telling patients outright that they are dying, and patients often resist hearing that message, said Dr. Douglas Blayney, immediate past president of ASCO.

“I never use the words ‘there is nothing more that can be done.’ We say ‘there is very little that will help us treat the cancer — we need to focus on you and your symptoms,'” Blayney said in a telephone interview.

“Often, in the hustle and bustle of the hospital, that conversation can be lost.”

Goodman agreed. “It really feels like a fight,” he said. “We tend to be really uncomfortable about sharing the news that cure is unlikely.”

Copyright 2010 Thomson Reuters.

By Maggie Fox, Health and Science Editor, November 16, 2010 for MSNBC.MSN.com

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