SEATTLE — Most people say that in their last two weeks of life they wouldn’t want to undergo chemotherapy. They wouldn’t want to be tethered to machines in an intensive-care unit or get other aggressive care – in fact, most say they’d rather die at home and not be in the hospital at all.

But what happens to dying cancer patients depends in large part on where they are – what region and what hospital system – according to a national report on the quality of end-of-life cancer care. The report, published Tuesday, looked at care given to elderly patients who died of advanced cancer.

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The lead author of a national report on the quality of end-of-life cancer care suggests that one of the reasons that hospitals focus on aggressive care for dying cancer patients is that doctors and nurses in general don’t talk with patients about their wishes early enough. 2009 Associated Press file

“We found that geography is destiny,” said Dr. David C. Goodman, lead author of the study by the Dartmouth Atlas Project, a research group, which for the last two decades has used Medicare data to document wide variations in how medical resources are distributed and used in the United States. The good news for Seattle residents: Cancer patients in their last month of life in Seattle were much less likely than patients in many other areas to receive CPR or get breathing tubes or feeding tubes – procedures considered “aggressive life-sustaining treatment” in the study.

In Manhattan, more than 18 percent of those patients underwent such procedures; in Seattle, 6.4 percent did.

On the other hand, similar patients in Olympia, Wash., had some of the highest likelihood of getting chemotherapy in their last two weeks of life: 12.6 percent of patients, more than twice the national average and four times the rate in Worcester, Mass.

The report, “Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses,” is based on records of nearly 236,000 Medicare patients with aggressive or metastatic cancer who died between 2003 and 2007.

Using billing records, the researchers looked at treatments, along with noting whether – and when – patients were referred to hospice care for help with pain control and quality-of-life issues for terminally ill patients. (Palliative-care programs do that, too, but for a broader range of patients.)

Fewer than half the patients in 50 academic medical centers got hospice services, the researchers found, and in some cases, the referral didn’t occur until a few days before the patient died.

“The well-documented failure in counseling patients about their prognosis and the full range of care options, including early palliative care, leads many patients to acquiesce to more aggressive care without fully understanding its impact on the length and quality of life,” Goodman said.

Goodman is co-principal investigator for the Dartmouth Atlas and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.

The study looked at regional variations and singled out some academic medical centers, including the University of Washington. In general, the UW hospital did well in the survey. Fewer than half the cancer patients were admitted to the hospital during their last month, compared to the two hospitals with the highest admission rates for such patients, both in Detroit, with 78 and 75 percent admission rates.

And only about 12 percent were admitted to the ICU in the last month of life, compared to close to 50 percent in some hospitals.

The UW hospital did not enroll patients in hospice care as often as many other hospitals, but the study did not account for palliative care.

The big, unanswered question: Why is there such variation in care?

Goodman said one explanation appears to be the number of hospital beds available in a community.

When a hospital system over time increases the number of ICU beds, the system tends to fill them, he said. “The differences are largely in how they happened to evolve over time,” Goodman said. And many hospitals don’t know where they stand relative to others until they see studies such as this one, he added.

Goodman noted that several studies have shown that aggressive care doesn’t necessarily prolong life – and in fact may shorten it – but is often reimbursed at a higher rate than palliative care.

Another reason why hospitals focus on aggressive care, he said, is that doctors and nurses are uncomfortable with an end-of-life discussion, and in general don’t talk with patients about their wishes early enough.

Dr. Stuart Farber, director of the palliative care service at the University of Washington Medical Center, puts it this way: A good editor will help a writer figure out what he or she wants to say and help the writer say it effectively. A bad editor will write it himself.

“If your doctor is helping you write the pages or last paragraphs of your life, if he finds out how you want to live, what’s important to you, he’s a good ‘editor,”‘ Farber says. “When you get all this chemotherapy, we’re writing the story for you.”

Dr. Tony Back, a UW specialist in cancer and in palliative care, says the best care tries to prolong life as long as possible, but also “optimizes quality of life,” and helps family members plan ahead. “Does anybody really think that having chemotherapy in the last week of life is a good thing?” he asked.

The large variation between regions and between hospitals shows there is no shared definition of quality care at the end of life, Back says. “There’s wild variations for no obvious good reason.”

In light of this, patients and families should realize they have choices, he says. “There are ways that a family and patients can take control of a difficult situation – take control and make proactive plans.”

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