The United States healthcare system is often berated for how it treats patients near the end of life. They are purportedly attached to tubes and machines and subjected to unnecessary invasive procedures that cause inordinate pain with no potential benefit, there is underutilization of more compassionate hospice services. This “travesty” is expensive, as the care of dying seniors consumes over 25% of Medicare expenditures. We hear this story so often; it is almost taken as gospel-- but is it actually true? Is it more expensive and invasive to die in America than in other developed countries?
Ezekiel Emanuel, MD is the elder, but less besieged, brother of Chicago’s mayor and a distinguished oncologist and vice provost at the University of Pennsylvania. He and his coworkers recently published the first systematic international comparison to test this hypothesis. They gathered end of life data from 2010 on cancer patients, as it is the second leading cause of death and the most expensive per patient. Surprisingly, the United States does compare fairly well in caring for these patients.
Just 22% of Americans dying with cancer actually died in the hospital, lower than in the six other countries involved in the study (Canada, England, Norway, the Netherlands, Belgium and Germany). Similarly, Americans spent the fewest days in the hospital in the last six months of life, on average ten days. In Canada, 52% of patients died in the hospital and nearly 90% were admitted for around three weeks during the last six months of life. In other areas, the United States did not measure up as well. The incidence of ICU admission and chemotherapy administration (40% each during final 180 days) were the highest of the countries studied. Most surprisingly, America was not the most expensive. We ranked more than the least expensive country, Norway, but comparable to Canada. This in spite of the fact that our total healthcare outlay per capita dwarfs the other six countries. This magnifies the relative over outlay of resources to the dying cancer population everywhere except here.
This study has important implications. If confirmed, it disproves the shibboleth that end of life care is a major contributor to our medical economic unsustainability. However, it also reinforces the avoidable human suffering from last ditch efforts to treat when there is little hope for improved quality of remaining days. It provides impetus to providing universal access to high-quality palliative care as the default for all Americans facing their demise.
By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton