American doctors are often portrayed as the most likely to treat terminally ill patients with aggressive, expensive, and unnecessary care in their final days, but is that fair?
It probably is, according to a study that was published Tuesday in the Journal of the American Medical Association and that compared care in the United States to care in six other industrialized nations.
The study analyzed health records of more than 389,000 cancer patients in the United States, Canada, Belgium, the Netherlands, England, Germany, and Norway over the last six months of their lives. It found that American cancer patients were more than twice as likely than those in other countries to end up in the intensive care unit, and American patients were more likely to receive chemotherapy.
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The United States also spent at least $18,500 per patient in their final months, roughly the same amount spent by Canada and Norway, but about twice as much as England.
“We’re still overusing the high-tech aspects of medical care,” said Dr. Ezekiel J. Emanuel, chairman of the department of medical ethics and health policy at the University of Pennsylvania and the study’s senior author. “The ICU, the chemotherapy, it seems like we can’t fully control ourselves when it comes to those high-tech elements.”
The United States did score well on at least one other metric.
Just 22.2 percent of patients died in a hospital, a smaller proportion than any other country. Even when including people who died in nursing homes and other institutions, the rate reaches only 29.5 percent, which is lower than any other nation but the Netherlands.
Patients in the United States have long expressed a desire to spend their final days at home, so physicians regard this particular statistic as a sign that the US health care system is becoming more responsive to patient preferences.
Emanuel acknowledged important limitations in the study’s findings, based on data from 2010 to 2012.
Chief among them is the fact that, although the study compared treatments for cancer patients, not all of the patients died of their cancers. Many prostate cancer patients in the United States, for instance, die of other diseases, and therefore might not have been receiving chemotherapy or other intensive cancer treatments in their final days.
As a result, treatment costs in the United States might be artificially low.
Meanwhile, unlike other nations, the United States does not include physician costs in its hospital cost data, which could add another 11.5 percent to total expenditures and therefore bring US costs closer to Canada’s per-patient expenditure of $21,840, the highest in the study.
For these and other reasons, Emanuel said he considers the study “hypothesis-generating and not definitive.”
Dr. Lachlan Forrow, director of palliative care programs at Boston’s Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School, said that despite the study’s limitations, it is important because it’s the first to offer such a broad comparison of end-of-life practices.
“We still don’t understand the problem in enough detail to actually know the best possible answers,” Forrow said. “So it’s a huge advance to actually have descriptions of the issues in six other health systems.”
Forrow said the data painted a slightly better picture of America’s end-of-life medical practices than he expected. “There are surprising things here, like the fact that fewer people in the US die in hospitals,” he said. “I was like, ‘Oh, whoa, I thought we were doing terrible at that.’”
One possible explanation: “A hospital day is so much more expensive that we’ve gotten people out of hospitals faster than other places,” he said.
For Dr. Neil S. Wenger, professor of medicine at University of California, Los Angeles, and a consulting researcher at RAND Corporation, that part of the study was less surprising. Wenger, who also noted the study’s methodological limitations, said the data are consistent with a common narrative in the United States.
Doctors and patients often pursue aggressive treatments to the very end, despite low odds of success, he said, “then rapidly transition to very brief period of comfort care before death.”
“And that’s considered a success.”