AP overtreatment series turns to last 6 months of life

From today’s latest addition to this excellent series:

“Americans increasingly are treated to death, spending more time in hospitals in their final days, trying last-ditch treatments that often buy only weeks of time, and racking up bills that have made medical care a leading cause of bankruptcies.

More than 80 percent of people who die in the United States have a long, progressive illness such as cancer, heart failure or Alzheimer’s disease.

More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project, which tracks health care trends.

Yet the numbers show that’s not what is happening.”

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Benjamin Atkinson

June 28, 2010 at 9:32 am

It has been my experience that people indicate a preference to avoid hospitalization…until death is near. It seems that once our ‘vital lie’ unravels we frantically search for any means to prolong life. Advance directives and healthcare powers of attorney often fall apart near the end of life. I suspect there is no administrative solution, but only a metaphysical solution.
Thank you for your insightful posts.

Gregory D. Pawelski

June 28, 2010 at 10:24 am

What a sorry state of affairs we have! Whatever clinical response that has resulted to the average number of patients in a randomized trial, is no indication of what will happen to an individual at any particular time. We have been trying to identify the “best guess” treatments for the average patient. You cannot mate notoriously heterogeneous diseases into “one-size-fits-all” treatments.
Remember a few years ago, a senior executive with Britain’s biggest drug company admitting that most prescription medicines do not work on most people who take them? It had been an open secret within the drug industry that most of its products were ineffective in most patients. But he was the first to have gone public with this.
Even finding tumor mutations to predict chemo success is still a “trial-and-error” approach to therapy. Doctors treating patients routinely apply the “trial-and-error” approach which says that if one drug does not work, there is always another one.
Testing for the EGFR mutation may be able to tell you whether or not your cells are “potentially” susceptible to this mechanism of attack. It cannot tell you if a “targeted” drug will work for “your” individual cancer cells. It is still a “trial-and-error” approach to therapy.
Sometimes targeted drugs can be used, but they can never find the correct one for the “individual” patient by using molecular tests (they never even test the drug against the tumor cells). Most times, targeted drugs need to be used with conventional cytotoxic chemotherapy. Sometimes they can find a combination of targeted drugs that may work.
What is still not understood by purveyors of the Cancer Genome Project is that the original Human Genome Project dealt with a homogeneous population of normal diploid cells. This is different from primary tumors, which are heterogeneous and have a genomic signature unique to every patient.
And the mutagenic (changes in form) effects of the wrong chemo can start the chain of metastatic events. A chemo-induced gene mutation can happen when the original chemo received does not work. The cancer can either continue to grow or comes back. When it does this, the tumor acts more aggressively. The mutagenic effects of chemotherapy on a genetically-unstable tumor, drives the tumor into a state of more aggressive behavior. You may even might kill off a whole lot of cancer, only to cause a mutation in the remaining cancer, such that the remaining cancer behaves in a more aggressive fashion.
Clearly, more effective cancer therapies are desperately needed, and after 30 years of investigation aimed at intensified multi-agent chemotherapy, we should look for other avenues of study. In an era of ever-increasing numbers of partially effective cancer therapeutics, there is an obvious need for more accurate methologies. We cannot afford any more ‘trial-and-error’ treatments.

Rose Hoban, BSN, MPH, Health Reporter

June 28, 2010 at 3:12 pm

This has been a great series and this is a great article. However, for the most part, it focused on young people dying. Their “do anything” attitude is understandable in light of all the life in front of them.
But, from my experience, what’s far more common, and more egregious (IMHO), are the extraordinary measures taken to prolong the lives of older people.
Boy, have I seen it.
Before entering journalism, I spent several years as a hospice nurse. I quickly lost count of the elderly patients who pulled on my sleeve in a quiet moment, asking me to convince their family members to let them go.
What was worse were the patients who had no clue they were dying. Their doctors had informed them, “I’ll send a nurse,” but they didn’t know why. So, I’d walk into a situation where there was no understanding of terminality. (My rough estimate was that this occurred about 20 percent of the time in a NYC hospice program in the mid-90s, so this is not a scientific sample)
Many of these patients, and/or their family members, were blind-sided. Some were relieved that all the treatment was done. Others, because no one had had a frank discussion with them, wanted to press on with more treatment. But I often saw these patients again, several days or weeks or months later, after more futile treatment.
Too many hadn’t been prepared for what was coming, and were dumbfounded and angry at the pain (surgeries, radiation, chemo) they’d been through ‘for nothing.’
Most of my old patients had desperately needed those ‘death panel’ discussions, but never got them. Many, many, many were grateful by the time I had left (I was the admissions nurse, so was first in the door) that someone had finally said the ‘D-word’ to them and asked them what they wanted.
That end-of-life counseling was carved out of the health reform bill was a real shame.
Sigh. Someday, I’m gonna write a book.