Care at the End of Life

One category of concentrated health spending is for care near the end of a patient’s life.  Several previous research analyses have indicated that much of this care is futile, a conclusion verified by a new review of multiple studies in an International Quality journal.   (Intl. Qual. Article)   As the introduction to the article indicates, much of the problem in controlling end-of-life care revolves around subjective patient and provider perceptions about the likelihood that an intervention will improve the patient’s condition for any extended period of time and around values about accepting death or fighting with every possible measure, regardless of likelihood of success.  And as you get further away from the actual date of death, it is obviously less apparent that the patient is in fact irrevocably terminal, so it is harder to know that a treatment might not help.  The authors advocate a concept of “non-beneficial treatment”, which attempts to create objective indices of the relationship between a treatment and the likelihood of patient improvement.  Using this concept, the authors conducted a review of multiple studies which included evaluation of care in the last six months of life.  38 studies were included, covering over 1,200,000 patients from 10 countries.  The authors conclude that around 10% of ICU use in the last six weeks of life was non-beneficial, that around a third of newly-initiated or continuing chemotherapy is non-beneficial and that a number of other treatments, diagnostics or procedures administered to patients near the end-of-life also had this status.  The likelihood of these useless treatments greatly increases when a patient is in the hospital.

Although not specified in this analysis, other research has indicated that tens of billions of dollars are spent annually on these futile treatments near the end-of-life.  To limit this from occurring, advance directives help, but intensive discussions with not only patients but their family and friends who often are decision makers are necessary to help them understand that further treatment not only isn’t going to make a difference but makes quality of death very poor.  Research consistently shows that most people would prefer to die at home, and to be able to communicate with family and friends near the end.  And at some point, as our overall fiscal crisis increases, physicians may need to be given the power to use their best judgment about whether a treatment is really likely to help.