Whether older cancer patients die in hospitals hooked up to
machines or at home surrounded by family has more to do with
hospital practices and geography than what the patient actually
wants, a study released this week has found.
Nearly one-third of patients over 65 with advanced cancer died
in a hospital, according to a study by the Dartmouth Atlas Group, a
leading authority on the U.S. health care system. Many received in
their final weeks intensive treatments like chemotherapy and
intubation that weren't going to change their odds and may have
affected the quality of their final days.
"Patients often unnecessarily receive care in intensive care
units and invasive procedures," said lead author Dr. David
Goodman. "On average, patients, particularly with advanced cancer,
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 to be whenever possible at home and with their
family."
Hospitals in the Tampa Bay area got better-than-average marks
from the Dartmouth Atlas Project, whose research received
significant attention during the debate on health care reform. In
Tampa, 24 percent of cancer patients on Medicare, the government
insurance plan for retirees, die in a hospital, compared with 35
percent in Miami. Some of the most intensive care occurred in
Manhattan, where 47 percent of cancer patients on Medicare died in
hospitals.
The health policy group, which is affiliated with Dartmouth
College in New Hampshire, examined a representative sample of
records from Medicare patients who died between 2003 and 2007. Most
of the half-million Americans who die of cancer annually are over
65.
Goodman said treatment patterns have evolved more by accident
than by design. Simply put, regions that have a lot of intensive
care units tend to use them. Those with strong hospice programs
steer patients there.
"The care patients receive has less to do with care they want
and more to do with the hospital they happen to seek care from,"
he said.
Physicians also have a hard time telling patients that a cure is
unlikely, Goodman noted. Their focus is fighting disease. But as a
cancer becomes terminal, many doctors struggle to speak honestly
about the odds and how treatment affects quality of life.
John Kinney was told that his wife had a fighting chance against
breast cancer right up until he was told she would die in two
days. Then he was diagnosed with lung cancer.
"I appreciated the doctor telling me you have lung cancer and
it's going to kill you and we can't do anything about it," said
Kinney, 75, who was given one to two years to live.
That was over a year ago. He received chemotherapy at Moffitt
Cancer Center in Tampa to slow the cancer's progression and has
undergone radiation to relieve pain. Moffitt doctors discussed
hospice services with him.
Now he is living at his daughter's South Tampa home, where
caregivers from LifePath Hospice in Hillsborough County check on
him weekly and are a phone call away if they are needed.
Kinney says he's living a good life, enjoying pleasures like
watching college football. His daughter, Kate Tomey, takes him out
for ice cream and dinners at Outback Steakhouse. He can shower by
himself and occasionally takes a short walk.
He hopes to stay at home as long as he isn't a burden to his
family; at that point, he can go to a hospice facility. Kinney
doesn't want intensive hospital care.
"I really can't get excited over dying. I had a good life,"
said Kinney, who had four children, three of whom are living, and
careers as a state trooper, schoolteacher and corrections officer,
among other jobs. "I'm kind of interested to see what's on the
other side."
Many cancer patients share his attitude, researchers said. But
end-of-life practices at the nation's hospitals range widely.
Moffitt hospitalized half of the Medicare patients studied during
their final month of life, the report noted. By comparison, two
Detroit hospitals admitted three-fourths of their patients.
Both Moffitt and Tampa General Hospital, also included in the
report, performed better than the national average on several key
indicators measuring aggressiveness of end-of-life care. Other
local hospitals' patient numbers weren't large enough to be
included in the report, but generally, it found Medicare patients
in Clearwater and Tampa were slightly less likely to die in
hospitals than were patients in St. Petersburg.
Dr. Lodovico Balducci, who leads Moffitt's senior adult oncology
program, said he speaks with cancer patients about treatment
preferences as early as possible.
It's a delicate talk, so he teams up with a social worker. Then
the focus turns to fighting the disease. But when it's clear
treatments cannot save them, Balducci talks openly about their
future and hospice referral.
"In 95 percent of the situations, people feel so much more
relaxed and satisfied when they can face" death, he said. "I tell
them that death is a very important aspect of life."
At Moffitt, about two-thirds of patients enroll in hospice
during the last month of their lives, the report found. That
compares to about half of patients nationally.
Tampa General reported similar hospice numbers to Moffitt, which
leaders say speaks to the strength of the region's hospice
programs. TGH's palliative care team spends a lot of time with
patients and families reviewing treatment choices.
"The goal of palliative care is discussing options," said Dr.
Vince Perron, TGH's associate chief medical officer . "It's never
to sway a patient or family to make a decision one way or another,
but you certainly want them to make an informed decision."
Letitia Stein can be reached at lsteinsptimes.com or (813)
226-3322. For more health news, visit www.tampabay.com/health.
c.2010 St. Petersburg Times