End-of-Life Care Around the World: U.S. Ranks ‘Surprisingly’ Well in Some Areas
If you are a terminally ill patient with cancer and you live in the United States, you are less likely to die in a hospital than you would if you lived in many other developed countries, according to a new first-of-its kind study comparing end-of-life care.
An international research team, which included Dartmouth Institute Assistant Professor Julie Bynum, MD, MPH, and researchers from the University of Pennsylvania’s Perelman School of Medicine in the United States, used data from 2010-2012 to compare end-of-life care in Belgium, Canada, England, Germany, the Netherlands, Norway and the United States. Measurements included hospitalizations, intensive care unit (ICU) admissions, ER visits and chemotherapy treatments in the last six months of life, as well as hospital expenditures paid by government or commercial insurers.
The U.S. had what would be considered positive rankings in several areas, refuting the widely held perception that end-of-life care in the U.S. is among the worst in the world. Only 22% of U.S. patients died in a hospital as compared to 51% of patients in Belgium and 52% of patients in Canada – ¾ the countries at the other end of the spectrum. Hospital stays for U.S. patients averaged 10 days in the last six months of life, as compared to 28 in Belgium and 25 in Norway – ¾ the countries with the highest average number of hospital days.
The study’s authors cite the 5,300 hospices in the U.S. (two-thirds of which provide home-based care) as one reason for the lower number of hospital deaths in the U.S. (In the early 1980s, more than 70% of U.S. cancer patients died in a hospital.)
On the negative side, although terminally ill patients with cancer in the U.S. spend less time in the hospital, they are more likely to receive costly, high-tech care and are twice as likely to be admitted to the ICU. In the last six months of life, 40% of U.S. patients with cancer were admitted to the ICU compared with less than 18% in the other reporting countries. Similarly, 40% of U.S. patients received chemotherapy at least once in the last six months of life, a use rate second only to Belgium. With the prevalence of expensive, resource-intensive care, it is perhaps not surprising that despite an overall low hospitalization rate in the last six months of life, the U.S. ranks third highest in average per patient hospital expenditure ($18,500), with only Canada ($21,840) and Norway ($19,783) spending more.
Bynum says that while the study highlights the fact that no country has ideal end-of-life health care practices, there is cause for optimism: “The U.S. has definitely improved over time, especially with hospice care and more people having the option to die at home (in accordance with their wishes). However, there is still a lot of work to be done particularly in terms of reducing costs and potentially unnecessary treatments.”