Monday, November 22, 2010


If elderly patients with incurable cancer would rather die at home, why do so many die in hospitals? Perhaps some of the answer is found in this odd truth that Atul Gawande has written about: Patients can understand a terminal diagnosis without accepting that they’re dying. The stated wish to die at home may be in conflict with, and even negated by, the desire to live as long as possible.

But where a patient lives in proximity to a medical center also impacts the likelihood that hospice care will be part of the end-of-life conversation, according to a report from the Dartmouth Atlas Project. The project’s first report on cancer care at the end of life studies quality of such care among medicare beneficiaries. The findings include:

+ “Even among the nation’s leading medical centers, there is no consistent pattern of care or evidence that treatment patterns follow patient preferences.”

+ “Many hospitals and physicians aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their last weeks and months.”

+ Clarity in communication is crucial. Patients want “honest conversations with their providers, ... balanced information about the chances of disease remission or progres-

sion, and the possible benefits and discomforts of different treatment options. Most

importantly, they want to be active partners with clinicians in making the decisions

about the type and place of care.”

+ “The use of hospice care varied markedly across regions and hospitals. In at

least 50 academic medical centers, less than half of patients with poor progno-

sis cancer received hospice services.”

+ “In some hospitals, referral to hospice care occurred so close to the day of death that it was unlikely to have provided much assistance and comfort to patients.”

To see the full report: