Discussing death with patients can cut costs, ease abandonment fears

New research shows communication's value. But dying patients who rely on religion to cope tend to opt for more aggressive care.

By Kevin B. O’Reilly — Posted March 30, 2009

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Three studies published in March highlighted the importance of improving physicians' conversations with dying patients.

Previous studies have shown that the 5% of Medicare patients who die each year account for 30% of Medicare's costs, with 78% of last-year-of-life expenses occurring in the month before death. But there may be a way to help reduce these costs, according a March 9 Archives of Internal Medicine study of 603 dying cancer patients at seven hospitals, oncology clinics and hospices.

The study found that patients who had conversations with their doctors about whether to focus on life extension or pain relief were more likely to die at home and spent less time in intensive care units, undergoing chemotherapy or on ventilators. Patients benefiting from talks with their doctors had a slightly better quality of life and survived just as long as those who did not have end-of-life-care discussions with physicians.

In the last week of life, care for patients who had discussions with their physicians cost $1,295, compared with $2,780 for patients who did not have such end-of-life talks. The study was funded by the National Institute of Mental Health and the National Cancer Institute as part of the ongoing Coping With Cancer Study.

A related investigation, also part of the Coping With Cancer Study, asked dying patients to complete a 14-item survey that measured the degree to which they rely on religion to help them contend with disease. Those with high levels of religious beliefs were much more likely to opt for ventilators and resuscitation and die in the ICU, said the March 18 study in the Journal of the American Medical Association.

Holly G. Prigerson, PhD, co-authored both studies and said very religious patients gain great comfort from their faith, but they could prolong aggressive treatment in hopes of a miracle.

"What this highlights for clinicians is to try to understand better how their patients are thinking about their illness and confirm how their religious beliefs are shaping their expectancy for cure," said Prigerson, director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute in Massachusetts. "We don't want to be in the position to tell clinicians what to do or to talk patients out of care. What the results highlight is where the patients' minds are at, and how many of them are disregarding a lot of their physicians' recommendations."

Prigerson said a multidisciplinary approach making better use of chaplain services could help highly religious patients.

Avoiding abandonment

Meanwhile, a third study found that once dying patients and their families decide to give up on treatment, they worry that their doctors will give up on them.

The researchers of the study, published in the March 9 Archives of Internal Medicine, interviewed nearly 150 doctors, nurses, patients and family caregivers and found that patients often felt abandoned by their physicians. After the patient's death, families longed for contact from doctors to help them gain a sense of closure.

One patient told researchers: "There isn't anything they can do. And I realize that, but they can hold my hand, so to speak, to the very end."

Physicians said they had to prioritize patients who could still benefit from treatment.

"There are only so many hours in the day, and I have, probably, at any one time, 10 to 20 patients on hospice," one unidentified doctor told researchers. "If I started calling them up, there would be this problem and that problem, and I would have to get in the middle of it. And quite frankly, it's care that's not reimbursed."

Anthony L. Back, MD, the study's lead author, said doctors should make an effort to close the loop with dying patients and their families. Dr. Back is a professor of oncology at the University of Washington School of Medicine and an oncologist at the Fred Hutchinson Cancer Center, part of the Seattle Cancer Care Alliance.

"These are tremendously important visits, and doctors should be able to bill for them," he said. "That said, these conversations with patients before death and families after death don't take long. ... The reason [doctors] are in this business is for moments like this, and I would hate to see them totally miss out."

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Talking makes a difference

Dying patients who talked with their doctors about their medical preferences received less aggressive -- and less expensive -- care during the last week of their lives than patients who did not. Study authors estimated these costs using nationally representative per capita charges.

Last week of
life outcomes
with doctor
Did not
Cost $1,925 $2,780
Place of death
Died at home 68.1% 55.9%
Died in hospital 21.7% 26.5%
Died in hospice 7.2% 4.4%
Died in ICU 2.9% 13.2%
Medical care received
Used outpatient hospice 77.3% 57.1%
Underwent chemotherapy 5.3% 10.0%
Stayed in ICU 2.7% 14.3%
Resuscitated 1.3% 8.6%
Used ventilator 1.3% 14.3%

Source: "Health Care Costs in the Last Week of Life," Archives of Internal Medicine, March 9 (link)

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External links

"Health Care Costs in the Last Week of Life," abstract, Archives of Internal Medicine, March 9 (link)

"Abandonment at the End of Life From Patient, Caregiver, Nurse, and Physician Perspectives," abstract, Archives of Internal Medicine, March 9 (link)

"Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer," abstract, Journal of the American Medical Association, March 18 (link)

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