End-of-Life Conversations Lower Costs, Improve Quality of Life
Article date: March 10, 2009
By Rebecca Viksnins Snowden
Advanced cancer patients who have end-of-life discussions with their doctors appear to have better quality of life in their final days and pay significantly less for that care, according to a new study published in the Archives of Internal Medicine.
The research is based on data from the ongoing Coping With Cancer study, a large multi-site study tracking the health of advanced cancer patients and their primary caregivers. It's being funded by the National Institute of Mental Health and the National Cancer Institute, and incorporates work from several research centers, including the Dana-Farber Cancer Institute, Yale University, Memorial Sloan-Kettering, and the University of Texas Southwestern Cancer Centers.
For this study, Harvard researchers at Dana-Farber Institute interviewed 603 patients and found 188 had discussed end-of-life care with their doctors. They found those patients were less likely to use more intensive interventions, and as a result, had lower medical bills. In fact, health costs for patients who had end-of-life conversations with their doctors were estimated to be an average of 36% lower in the last week of life than for patients who didn't talk with their doctors.
There was no difference in survival or in psychological distress between the two groups. However, patients who didn't have end-of-life conversations with their doctors experienced more physical distress in the final week of life, as reported by nurses and caregivers.
"We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive, burdensome, non-curative care, like being on a ventilator in an intensive care unit, to less costly comfort care provided at home or in hospice, which most patients and their families say they would prefer," said Holly G. Prigerson, PhD, of the Center for Psycho-Oncology and Palliative Care Research at the Dana-Farber Cancer Institute and an author of the study.
Studies have shown that about one-third of Medicare expenditures in the last year of a person's life are spent in the last month. A high proportion of those costs come from life-sustaining procedures and care, such as ventilator use and resuscitation.
Promoting policies that increase communication between doctors and patients could lead to better quality-of-life and lower costs at the end-of-life for patients with advanced cancer, the researchers conclude.
In another study published in the same issue of the Archives of Internal Medicine, researchers analyzed data from 158,780 Medicare patients who died in 2001 and found that despite dying of similar causes, black and Hispanic patients appeared to have significantly higher end-of-life costs than white patients. Most of this was due to greater use of life-sustaining care and procedures. The researchers weren’t able to look at the reasons for these differences in the study.
"These reports help shed light on an important issue: differences between certain populations in end-of-life care, including lower rates of hospice use among certain populations," says Otis W. Brawley, MD, chief medical officer of the American Cancer Society. "But the issue here may not be about race as much as it is about economics and culture. People who do not have adequate access to health care often do not have an ongoing relationship with a specific doctor. Without a regular source of care, there's less opportunity to build a trusting relationship."
More research is needed, he says.
"These are important, intriguing findings, but it's important that other researchers replicate them before we draw further conclusions. Once that's done, we'll need to explore in more detail what factors may contribute and how. But this data clearly supports the need for further research."
For more information about end-of-life issues and concerns, see our document, Nearing the End of Life.
Citation: "Health Care Costs in the Last Week of Life." Published in the March 9, 2009 issue of the Archives of Internal Medicine. Corresponding author: Holly G. Prigerson, PhD, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute. Boston, Massachusetts.
"Racial and Ethnic Differences in End-of-Life Costs." Published in the March 9, 2009 issue of the Archives of Internal Medicine. Corresponding author: Ezekiel Emanuel, MD, PhD, National Institutes of Health, Bethesda, Maryland.
Reviewed by: Members of the ACS Medical Content Staff
ACS News Center stories are provided as a source of cancer-related news and are not intended to be used as press releases.
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