Studies Investigate Health Care at the End of Life

Patients with advanced cancer who discuss end-of-life care with their physicians appear to have lower health care costs in the final week of life than those who do not, according to a report in the March 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. A second report finds that black and Hispanic patients tend to have higher health care costs at the end of life than white patients, despite dying of similar causes. Two other articles in the same issue examine dying patients’ feelings of abandonment by physicians and reasons that patients request physician aid in dying in Oregon.

A disproportionate share of medical costs occur at the end of life, according to background information in the first article. Almost one-third of Medicare expenditures are attributable to the 5 percent of beneficiaries who die each year, and about one-third of expenses in the last year of life are spent in the final month. Previous studies suggest that most of these costs result from life-sustaining care, including resuscitation and mechanical ventilation.

Baohui Zhang, M.S., of the Dana-Farber Cancer Institute, Boston, and colleagues studied 603 patients who were part of the Coping With Cancer study, funded by the National Institute of Mental Health and the National Cancer Institute. At the beginning of the study—between 2002 and 2007—188 (31.2 percent) reported discussing their wishes about end-of-life care with their physicians. They were then followed up through death.

In the final week of life, patients who reported having end-of-life discussions with their physicians had average aggregate health care costs of $1,876, compared with $2,917 for patients who did not. Formal and informal caregivers who were interviewed after patients’ deaths reported that those with higher costs also had a worse quality of death in their final week.

In the second article about end-of-life costs, Amresh Hanchate, Ph.D., of Boston University School of Medicine, and colleagues report on an analysis of data from 158,780 Medicare beneficiaries who died in 2001. In the last six months of life, costs varied significantly by racial and ethnic background—costs for whites averaged $20,166, compared with $26,704 for blacks and $31,702 for Hispanics.

“Although 40 percent to 60 percent of these excess differences are associated with geography, i.e., living in high–medical-expenditure areas, substantial differences remain, even after adjustment for many patient characteristics in addition to geographic variables,” the authors write. “Strikingly higher rates of use of intensive end-of-life treatments such as ICU [intensive care unit] and ventilators account for most of these residual differences.”

“Therefore, at life’s end, minorities often receive more expensive but not necessarily life-enhancing care,” they conclude. “It is unclear how much of this was actively sought, or the extent to which racial and ethnic differences are principally driven by how choices are presented or how they are ‘heard.’ These would be fruitful questions for future research.”(Arch Intern Med. 2009;169[5]:480-488, 493-501. Available pre-embargo to the media at www.jamamedia.org.)