October 6, 2011
Are End-of-life Surgeries Overused?
A new Harvard study has found that it is surprisingly common for older people to undergo surgery in the last year, month and even week of their life, a finding that is likely to fuel the debate over whether medical care is overused and needlessly driving up medical costs.
The study also found that age and where the people live may have even more to do with whether elderly Americans undergo surgery than their actual medical need or desire for the procedures.
Nearly a third of the 1.8 million Medicare recipients who were at least 65 years old and died in 2008 had surgery in the last year of life, nearly 20 percent had it in the last month of life, and 10 percent in the last week of life, researchers from Harvard School of Public Health reported in an online publishing in the medical journal The Lancet.
Ashish Jha, a professor of health policy and management at Harvard and study author, said many of the operations probably failed to improve dying patients´ lives. “In a lot of places, we´re doing a lot of these surgeries I think unnecessarily,” he said. “We´re not having the kinds of conversations with patients that we need to have, about what they want out of their last few days and how we help them achieve those goals.”
In Muncie, Indiana, where end-of-life surgeries were most common, more than 34 percent of elderly Medicare recipients had procedures in the year before they died, according to the report released Wednesday. The lowest rate of end-of-life surgeries came from Honolulu, Hawaii, where less than 12 percent underwent surgery in that period.
The likelihood of undergoing end-of-life surgery declines as patients age, the study found. More than 38 percent of Medicare recipients who died in 2008 had surgery in the last year of life, while 35 percent of those who died at age 80, had the end-of-life surgery. Of those who died between the ages of 80 and 90, only 24 percent underwent such operations.
“My sense is that a lot of surgeons are still uncomfortable with doing surgery on the very elderly, and that´s why they back off,” Jha told Bloomberg's Molly Peterson. Many physicians shy away discussing how dying patients want to spend their remaining days on Earth.
“We need a much more concerted effort to encourage and train physicians to talk to their patients about their wishes at the end of life,” he added.
But such analyses are controversial. By looking only at the people who died, researchers can get a biased picture of what is happening, according to critics of the study.
“Because the patient died, you can´t assume that the treatment and therapies were not of value,” Dr. Peter B. Bach of Memorial Sloan-Kettering Cancer Center, told the New York Times. “Although in that individual, things may not have worked out, you have no insight into whether the decision to operate was appropriate.” Nor is it known how many similar patients who had the same surgery did not die.
The researchers acknowledged that they did not know why the operations they analyzed had been done, or why there were so many in the study period. They speculated that some were necessary to relieve pain and suffering or to prolong life. But, they said, they know from experience that doctors often operate to repair something that can be fixed but that will not save a dying patient, avoiding difficult discussions with patients about their prognosis and whether the surgery will improve quality of life or not.
Dr. Scott Ramsey, an economist and a physician who is director of cancer outcomes research at the Fred Hutchinson Cancer Research Center in Seattle, criticized the researchers for citing regional differences but then suggesting a long list of factors that might be causing them, including the health of the population, the patterns of medical practice, and the availability of hospice care and other end-of-life services.
Their list of potential explanations “covers about everything and says absolutely nothing,” Dr. Ramsey told Gina Kolata of the New York Times.
But the researchers said their study probably pointed to a real problem in American medicine: surgery, which can be painful, expensive and debilitating, is tempting for doctors and patients alike.
“I will admit to being guilty of this,” Dr. Jha told Kolata. “Often we say, ℠If you have this intervention, we will be able to fix that problem. You have an intestinal blockage. Surgery will fix it.´ But will it let you walk out of the hospital alive? Will it let you return to your old life?”
“Evidence like this – and a lot of previous evidence, directly from patients and their families – shows that we need much better support for patients and their families when they have serious illnesses and may need intensive treatments,” Dr. Mark McClellan, a former commissioner of the Centers for Medicare and Medicaid Services, who directs the Engelberg Center for Health Care Reform at the Brookings Institution, told NY Times.
Jha said he would continue to study causes and consequences of surgery at the end of life, adding, “It is hard to take these data and make clear policy recommendations about what is appropriate and what is not.”
But he said difficult conversations that should precede a decision to operate often never occur. “As clinicians, we often end up focusing on something narrow and small that we think we can fix,” he said. “That leads us down the path of surgical intervention. But what the patient cares about is not going to get fixed.”
Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.
“No one had talked to him about how close he was to death,” Jha told Kolata. “It´s the worst kind of conversation to have.”
Instead, doctors performed an endoscopy and a colonoscopy because the man had internal bleeding. Then they did an abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Jha explained.
The man died of complications from the surgery.
“The tragedy is what we should have done for him but didn´t,” Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can´t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”
Reasoning behind taking the option to perform surgery could have something to do with the fact that doctors and hospitals are guaranteed to receive pay from Medicare for performing the procedures, “regardless of the patient´s preferences or goals,” said Amy Kelley, an assistant professor of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine in New York.
“Policy makers must align incentives for insurance plans, health-care institutions, and providers with individual patients´ goals,” Kelley said in a commentary that accompanied the study.
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