The Cost of Intensive End-of-Life Care

End-of-life care has often been scrutinized for unnecessary and expensive care that is somewhat obviously, at least in hindsight, futile.  A new study examines intensity of care among cancer patients among Medicare and VA beneficiaries in the last year of life.   (JAMA Geriatrics Study)    While cancer has become a more treatable disease, it still is relatively apparent at some point that the patient is not going to survive.  The National Quality Forum has come up with a list of what it considers to be intensive services.  Despite specialty society recommendations to avoid such care and use palliative measures, many people still get intensive care, which is not linked to better outcomes and which has a high cost.  The focus of this study was on the last month of life for veterans who were Medicare eligible and died of cancer from 2010 to 2014 and their receipt of intensive care in that last month.  Intensive care was defined as two or more ER visits, chemotherapy, an ICU stay, any hospital admission or hospice use for less than three days.  The costs to Medicare, the VA and the patient of the care received was also tallied.

The median patient had a cancer diagnosis for almost three years prior to death.  59% of the patients received at least one intensive care service in the last month of life.  The most common one was too little hospice use, followed by any hospital stay.  It wasn’t clear whether hospice use meant only in a facility.  People can and often do receive palliative care at home.  Patients with at least one intensive service had about $16,000 greater medical spending in that last month compared to those who had none.  They also had about $1130 more spending for which they were responsible, which likely adds to stress levels.  ICU stays added the most expense.  In total, avoiding intensive care for all patients would probably save Medicare alone a few billion dollars a year.  Given the costs to the system, and to the beneficiary, and given that intensive care truly is futile, treating physicians for cancer patients have a special obligation to ensure that patients understand their prognosis and understand that they will almost certainly have a better quality of death if they accept palliative care.  Other research has suggested that doctors do a poor job of adequately communicating prognoses, especially bad prognoses, to patients.  While no one likes to be the bearer of bad news, for physicians it comes with the territory.