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Medical Practice Variations in End-of-Life Care

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Medical Practice Variations

Part of the book series: Health Services Research ((HEALTHSR))

Abstract

Across the world today, population aging is occurring at an unprecedented rate; the most rapidly growing are those aged 80 and over. This demographic trend highlights the growing demand of health care for the elderly and a corresponding need to examine international end-of-life care practices in order to inform the provision of best quality of care for this segment of the population. End-of-life care accounts for a substantial proportion of health care expenditures – up to 25 % of public healthcare funding – in many countries, although age per se may be a relatively minor determinant of costs of care at the end of life. End-of-life care as a distinct goal or practice of medicine is a relatively new concept. In the past century, the shift away from acute infectious diseases as the major cause of worldwide death, towards more complex chronic diseases, led increasingly to the development of palliative and hospice care. Currently there is wide global variation in capacity for such care, including location of death, availability of formal palliative and hospice care in both acute care settings and at home. There is also large variation in the roles of decision makers (patients, families, healthcare professionals) and the use of advance care planning and directives to inform such care, seemingly influenced by ethnicity, race and religion of individuals, and regions. Occasionally, this variation leads to conflict in decision making; very few countries have evolved formal resolution options that involve patients, families, healthcare providers, bioethicists, and legal or quasilegal bodies. Despite such variation, evidence suggests that care providers from various parts of the world encounter similar challenges in the provision of end-of-life care. Examining international variation in end-of-life care provides examples of differing levels of systems performance that can inform end-of-life care quality improvement initiatives for all systems.

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References

  • Abel J, Rich A, Griffin T, et al. End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year. Palliat Med. 2009;23(7):616–22.

    Article  CAS  PubMed  Google Scholar 

  • Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;375:1339–46.

    Article  Google Scholar 

  • American College of Physicians. Achieving a high performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med. 2008;148:55–75.

    Article  Google Scholar 

  • Ball C, Navsaria P, Kirkpatrick A, et al. The impact of country and culture on end-of-life care for injured patients: results from an international survey. J Trauma. 2010;69(6):1323–33.

    Article  PubMed  Google Scholar 

  • Bardsley M, Georghiou T, Dixon J. Social care and hospital use at the end of life. London: Nuffield Trust; 2010.

    Google Scholar 

  • Boseley S, Sparrow A. Johnson lifts NHS ban on top-up treatment. Guardian Newspaper. Available at: http://www.theguardian.com/politics/2008/nov/04/nhs-health-cancer-topup-treatment. Accessed 19 Nov 2013.

  • Brockmann H. Why is less money spent on health care for the elderly than for the rest of the population? Health care rationing in German hospitals. Soc Sci Med. 2002;55(4):593–608.

    Article  PubMed  Google Scholar 

  • Bruera E, Neumann C, Mazzocato C, et al. Attitudes and beliefs of palliative care physicians regarding communication with terminally ill cancer patients. Palliat Med. 2000;14(4):287–98.

    Article  CAS  PubMed  Google Scholar 

  • Bruera E, Sweeney C. Palliative care models: international perspective. J Palliat Med. 2002;5(2):319–27.

    Google Scholar 

  • Canadian Institute for Health Information. Health care use at the end of life in Western Canada. Ottawa: CIHI; 2007.

    Google Scholar 

  • Chao L, Pagán J, Soldo B. End-of-life medical treatment choices: do survival chances and out-of-pocket costs matter? Med Decis Making. 2008;28(4):511–23.

    Article  PubMed Central  PubMed  Google Scholar 

  • Clark D, Wright M. The international observatory on end of life care: a global view of palliative care development. J Pain Symptom Manage. 2007;33(5):542–6.

    Article  PubMed  Google Scholar 

  • Costantini M, Romoli V, Leo SD, Beccaro M, Bono L, Pilastri P, Miccinesi G, Valenti D, Peruselli C, Bulli F, Franceschini C, Grubich S, Brunelli C, Martini C, Pellegrini F, Higginson IJ, The Liverpool Care Pathway Italian Cluster Trial Study Group. Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial. Lancet. 2013;6736(13):61725.

    Google Scholar 

  • den Block LV, Deschepper R, Bossuyt N, Drieskens K, Bauwens S, Van Casteren V, Deliens L. Care for patients in the last months of life. The Belgian Sentinel Network Monitoring End-of-Life Care study. Arch Intern Med. 2008;168(16):1747–54.

    Article  PubMed  Google Scholar 

  • Department of Health. End of life care strategy fourth annual report. London: NHS; 2012.

    Google Scholar 

  • Economist Intelligence Unit. The quality of death: ranking end-of-life care across the world. London/New York/Hong Kong: The Economist; 2010.

    Google Scholar 

  • Emanuel E, Emanuel L. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221–6.

    Article  CAS  PubMed  Google Scholar 

  • Esteban A, Gordo F, Solsona J, et al. Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-center observational study. Intensive Care Med. 2001;27(11):1744–9.

    Article  CAS  PubMed  Google Scholar 

  • Evans T, Nava S, Mata G, et al. Critical care rationing: international comparisons. Chest. 2011;140(6):1618–24.

    Article  PubMed  Google Scholar 

  • Fassier T, Lautrette A, Ciroldi M, et al. Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care. 2005;11(6):616–23.

    Article  PubMed  Google Scholar 

  • Felder S, Werblow A, Zweifel P. Do red herrings swim in circles? Controlling for the endogeneity of time to death. J Health Econ. 2010;29(2):205–12.

    Article  PubMed  Google Scholar 

  • Ferrand E, Robert R, Ingrand P, et al. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet. 2001;357(9249):9–14.

    Article  CAS  PubMed  Google Scholar 

  • Fine RL, Mayo TW. Resolution of futility by due process: early experience with the Texas Advance Directives Act. Ann Intern Med. 2003;138:743–6.

    Article  PubMed  Google Scholar 

  • Fried TR, O’Leary J, Van Ness P, Fraenkel L. Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment. J Am Geriatr Soc. 2007;55(7):1007–14.

    Article  PubMed Central  PubMed  Google Scholar 

  • Frost D, Cook DJ, Heyland DK, Fowler RA. Patient and health care professional factors influencing end-of-life decision-making during critical illness: a systematic review. Crit Care Med. 2011;39(5):1174–89.

    Article  PubMed  Google Scholar 

  • Gajewska K, Schroeder M, De Marre F, et al. Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit. Intensive Care Med. 2004;30(6):1224–7.

    Article  PubMed  Google Scholar 

  • Giannini A, Pessina A, Tacchi E. End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting. Intensive Care Med. 2003;29(11):1902–10.

    Article  PubMed  Google Scholar 

  • Gomes B, Higginson I, Calanzani N, et al. Preferences for place of death if face with advanced cancer: a population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. Ann Oncol. 2012;23(8):2006–15.

    Article  CAS  PubMed  Google Scholar 

  • Gray B. England’s approach to improving end-of-life care: a strategy for honoring patients’ choices. Issue Brief (Commonw Fund). 2011;15:1–15.

    Google Scholar 

  • Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs. Crit Care Med. 2004;32:1254–9.

    Article  PubMed  Google Scholar 

  • Heyland D, Lavery J, Tranmer J, et al. Dying in Canada: is it an institutionalized, technologically supported experience? J Palliat Care. 2000;16(Suppl):S10–6.

    PubMed  Google Scholar 

  • Heyland DK, Barwich DB, Pichora D, Dodek P, Lamontagne F, You JJ, Tayler C, Porterfield P, Sinuff T, Simon J, ACCEPT (Advance Care Planning and Evaluation in Elderly Patients) Study Team, Canadian Researchers at the End of Life Network (CARENET). Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778–87.

    Article  PubMed  Google Scholar 

  • Himsworth R, Goldacre M. Does time spent in hospital in the final 15 years of life increase with age at death? A population based study. Br Med J. 1999;319(7221):1338–9.

    Article  CAS  Google Scholar 

  • Holzapfel L, Demingeon G, Piralla B, et al. A four-step protocol for limitation of treatment in terminal care. An observational study in 475 intensive care unit patients. Intensive Care Med. 2002;28(9):1309–15.

    Article  PubMed  Google Scholar 

  • Kardamanidis K, Lim K, Da Cunha C, et al. Hospital costs of older people in New South Wales in the last year of life. Med J Aust. 2007;187(7):383–6.

    PubMed  Google Scholar 

  • Kelley MA, Angus D, Chalfin DB, Crandall ED, Ingbar D, Johanson W, Medina J, Sessler CN, Vender JS. The critical care crisis in the United States: a report from the profession. Chest. 2004;125:1514–7.

    Article  PubMed  Google Scholar 

  • Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision-making. J Gen Intern Med. 2005;20(6):531–5.

    Article  PubMed Central  PubMed  Google Scholar 

  • Lo B, Steinbrook R. Resuscitating advance directives. Arch Intern Med. 2004;164(14):1501–6.

    Article  PubMed  Google Scholar 

  • Lubitz J, Prihoda R. The use and costs of Medicare services in the last 2 years of life. Health Care Financ Rev. 1984;5(3):117–31.

    PubMed Central  CAS  PubMed  Google Scholar 

  • Lubitz J, Cai L, Kramarow E, Lentzner H. Health, life expectancy, and health care spending among the elderly. N Engl J Med. 2003;349(11):1048–55.

    Article  CAS  PubMed  Google Scholar 

  • Luce J, Lemaire F. Two transatlantic viewpoints on an ethical quandary. Am J Respir Crit Care Med. 2001;163(4):818–21.

    Article  CAS  PubMed  Google Scholar 

  • Lutz S. The history of hospice and palliative care. Curr Probl Cancer. 2011;35(6):304–9.

    Article  PubMed  Google Scholar 

  • Lynch T, Connor S, Clark D. Mapping levels of palliative care development: a global update. J Pain Symptom Manage. 2013;45(6):1094–106.

    Article  PubMed  Google Scholar 

  • Meier D, Fuss B, O’Rourke D, et al. Marked improvement in recognition and completion of health care proxies. A randomized controlled trial of counseling by hospital patient representatives. Arch Intern Med. 1996;156(11):1227–32.

    Article  CAS  PubMed  Google Scholar 

  • Melberg HO, et al. Costs towards the end of life. J Norw Med Assoc. 2012;133:841–4.

    Google Scholar 

  • Menec V, Lix L, Nowicki S, et al. Health care use at the end of life among older adults: does it vary by age? J Gerontol A Biol Sci Med Sci. 2007;62(4):400–7.

    Article  PubMed  Google Scholar 

  • Morrison R, Meier D. High rates of advance care planning in New York City’s elderly population. Arch Intern Med. 2004;164(22):2421–6.

    Article  PubMed  Google Scholar 

  • Ontario Consent and Capacity Board. Available at: http://www.ccboard.on.ca. Accessed 14 Mar 2013.

  • Pardon K, Deschepper R, Vander Stichele R, EOLIC-consortium, et al. Changing preferences for information and participation in the last phase of life: a longitudinal study among newly diagnosed advanced lung cancer patients. Support Care Cancer. 2012;20(10):2473–82.

    Article  PubMed  Google Scholar 

  • Pendergast T, Claessens M, Luce J. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163–7.

    Article  Google Scholar 

  • Poisal JA, Truffer C, Smith S, Sisko A, Cowan C, Keean S, Dickensheets B. Health spending projections through 2016: modest changes obscure part D’s impact. Health Aff. 2007;26:w242–53.

    Article  Google Scholar 

  • Polder J, Barendregt J, van Oers H. Health care costs in the last year of life – the Dutch experience. Soc Sci Med. 2006;63(7):1720–31.

    Article  PubMed  Google Scholar 

  • Raijmakers N, van Zuylen L, Costantini M, et al. Issues and needs in end-of-life decision making: an international modified Delphi study. Palliat Med. 2011;26(7):947–53.

    Article  PubMed  Google Scholar 

  • Scala-Foley M, Caruso J, Archer D, et al. Medicare’s hospice benefits: when cure is no longer the goal, Medicare will cover palliative care. Am J Nurs. 2004;104(9):66–7.

    Article  PubMed  Google Scholar 

  • Schroeder SA. Shattuck Lecture. We can do better–improving the health of the American people. N Engl J Med. 2007;357:1221–8.

    Article  CAS  PubMed  Google Scholar 

  • Seow H, King S, Vaitonis V. The impact of Ontario’s end-of-life care strategy on end-of-life care in the community. Healthc Q. 2008;11(1):56–62.

    Article  PubMed  Google Scholar 

  • Shugarman L, Decker S, Bercovitz A. Demographic and social characteristics and spending at the end of life. J Pain Symptom Manage. 2009;38(1):15–26.

    Article  PubMed  Google Scholar 

  • Sjökvist P, Nilstun T, Svantesson M, et al. Withdrawal of life support – who should decide? Differences in attitudes among the general public, nurses and physicians. Intensive Care Med. 1999;25(9):949–54.

    Article  PubMed  Google Scholar 

  • Sprung C, Maia P, Bulow H, et al. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33(10):1732–9.

    Article  PubMed  Google Scholar 

  • Supreme Court of Canada Reports. Cuthbertson vs. Rasouli. File 34362. 2013 SCC 53.

    Google Scholar 

  • Tariman JD, Berry DL, Cochrane B, Doorenbos A, Schepp K. Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. Ann Oncol. 2010;21(6):1145–51.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  • Truog R, Brock D, Cook D, et al. Rationing in the intensive care unit. Crit Care Med. 2006;34(4):958–63.

    Article  PubMed  Google Scholar 

  • United Nations. Probabilistic population projections. Available at: http://esa.un.org/unpd/ppp/index.htm. Accessed 14 Mar 2013.

  • Vincent J. Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med. 1999;27(8):1626–33.

    Article  CAS  PubMed  Google Scholar 

  • Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK. Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ. 2004;328(7440):607.

    Article  PubMed Central  PubMed  Google Scholar 

  • White D, Curtis J. Care near the end-of-life in critically ill patients: a North American perspective. Curr Opin Crit Care. 2005;11(6):610–5.

    Article  PubMed  Google Scholar 

  • Wilson D, Smith S, Anderson M, et al. Twentieth-century social and health-care influences on location of death in Canada. Can J Nurs Res. 2002;34(3):141–61.

    PubMed  Google Scholar 

  • World Health Organization. Composition of world health expenditures. Available at: www.who.int/nha/Pie-2007.pdf. Accessed 14 Mar 2013.

  • Wunsch H, Angus D, Harrison D, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36(10):2787–93.

    Article  PubMed  Google Scholar 

  • Zweifel P, Felder S, Meier M. Reply to: econometric issues in testing the age neutrality of health care expenditure. Health Econ. 2001;10(7):637–74.

    Article  Google Scholar 

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Acknowledgements

Heart and Stroke Canada (Ontario)

Canadian Institutes for Health Research

The University of Toronto Integrating Challenge Fund

The Commonwealth Fund & Harkness Fellowship Program

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Authors and Affiliations

  1. Faculty of Medicine, University of Toronto, Toronto, Canada

    Michael Hammer

  2. University of Oslo, Oslo, Norway

    Hans Olav Melberg

  3. Departments of Medicine and Critical Care Medicine, Sunnybrook Hospital, University of Toronto, 2075 Bayview Ave., Room D478, M4N 3M5, Toronto, ON, Canada

    Robert Fowler

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  1. Michael Hammer
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  2. Hans Olav Melberg
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Correspondence to Robert Fowler .

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Editors and Affiliations

  1. Department of Public Health Sciences, Queen's University Centre for Health Services and Policy Re, Kingston, Canada

    Ana Johnson

  2. Institute for Clinical Evaluative Scienc, Toronto, Ontario, Canada

    Thérèse Stukel

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Hammer, M., Melberg, H.O., Fowler, R. (2013). Medical Practice Variations in End-of-Life Care. In: Johnson, A., Stukel, T. (eds) Medical Practice Variations. Health Services Research. Springer, Boston, MA. https://doi.org/10.1007/978-1-4899-7573-7_79-1

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  • DOI: https://doi.org/10.1007/978-1-4899-7573-7_79-1

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