A compassionate end

You probably don’t spend a lot of time thinking about how you’ll die. But when you do, you’d probably agree with most Americans that dying comfortably at home is the way to go.

But this is not what’s happening. It turns out that how you die depends a lot more on where you live than what you want.

The Dartmouth Atlas Project recently came out with its first-ever report on end-of-life-care for people with advanced cancer. The report’s authors concluded that “many clinical teams aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their life in their last weeks and months.”

They found no evidence that treatment patterns followed patient preferences. The care people with life-ending cancers received in their final weeks or months varied dramatically from location to location, with nearly one-third dying in a hospital and about half receiving hospice care.

Sacramento comes in right at the national average: 29 percent of elderly people with Medicare dying from advanced cancer between 2003 and 2007, when the Dartmouth data was collected, spent their last days in a hospital.

For Frederick Meyers, a UC Davis oncologist and executive associate dean who oversees the research, teaching, clinical-care and community-engagement missions of the medical school, that’s an encouraging statistic. But it’s not good enough.

Research shows limited or no benefit for aggressive treatments in advanced-cancer cases, and Meyers said the variation in treatments relates to fluctuations in quality of care provided at different institutions, hospitals and providers.

There are a number of reasons for the variations, including patient wishes, research into new treatments at university hospitals, availability of hospice services or even relatives who can help with end-of-life care. A health system’s culture also explains part of it, said Meyers, who, as a longtime leader of the national hospice movement, believes that effective palliative care—relieving suffering rather than focusing on curing disease—is very often the appropriate care for patients with end-stage cancer.

At UC Davis, one of the first university systems to have a hospice, more than half of the patients in the Dartmouth report, 53.1 percent, received hospice services. “At UC Davis and in Sacramento, everyone can get hospice services,” Meyer said. “Even if they’re uninsured, we’ve always served everyone.”

Meyers agrees that most people with advanced cancer don’t want extraordinary methods used to prolong their lives at the expense of the quality of life during their last days. It’s a doctor’s responsibility, he said, to help a patient who might want aggressive treatment understand when it won’t help.

“Ethically, physicians don’t have to provide treatment they think is inappropriate,” Meyers said. “When you explain it to them, most patients say, ‘You’re right. I should go home and spend time with family.’”

The problem, said the lead author of the Dartmouth report, David C. Goodman, is that sick people too often aren’t aware of their options. “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.”

Meyers estimates that today more than 80 percent of hospitals have implemented consultations by palliative-care specialists, and efforts are increasingly being made to incorporate palliative care with treatment of disease. He’s optimistic that when the Dartmouth Atlas Project releases a future report, it will reveal an upward trend in more recent years toward appropriate end-of-life care.