End-of-life care should focus on quality of life, not prolonging it

by Lachlan Gilbert, University of New South Wales

Credit: Shutterstock

Terminally ill, older adults would prefer to receive higher quality supportive care rather than aggressive end-of-life treatments to prolong their lives, a UNSW Sydney study has found.

21 feb 2019--In an article published recently in the journal Health Expectations, the authors interviewed 24 older adults in NSW who were either terminally ill or cared for a person faced with advanced or irreversible disease, to determine whether their end-of-life (EOL) care needs were being met. The researchers were then able to identify a list of common themes that patients or their caregivers expressed about their health care experience.

The seven themes were identified as follows: quality as a priority; a desire for a sense of control; living a life on hold; the need for health system support; a preference for being at home; talking about death; and dealing with competent and caring health professionals. An underpinning priority throughout the seven themes was knowing and adhering to patient's wishes.

To date, much of the research concerning consumer preferences around end-of-life care has been undertaken in the oncology setting. But according to lead author of the study, UNSW School of Public Health and Community Medicine's Ebony Lewis, the latest findings look at older terminal patients with a range of chronic conditions beyond cancer, as well as including caregivers.

Ms Lewis says the study found that older terminally ill health care consumers and caregivers have a strong community-based preference for less aggressive EOL treatments and higher quality supportive care in line with their personal values. But despite this, many older Australians are still spending their last weeks of life in hospital.

"While the government recognises the importance of providing high-quality and safe end-of-life care, and has developed guiding principles for its provision, our consultation found that 'real life' alternative options for end-of-life care outside the acute hospital may not be available,"Ms Lewis says.

"Urgent strategies are needed to support terminal care outside the acute hospital as well as tools to give health care professionals the ability to deliver more skilled end-of-life communication that incorporates the patients' personal values."

Ms Lewis says such action would address this gap in services as well as the unmet care needs of older adults and relatives caring for dying patients, which ultimately affects everyone in society.

"The general community is also affected by the traumatic experiences of their elders whose suffering and dying processes are prolonged without gains in quality end-of-life. This can leave families with great regret and can cause dissatisfaction with health services."

Ageing population

The fact that the proportion of those over 65 in the Australian population is expected to double in the next 30 years is also a pressing concern for Ms Lewis.

"Our growing ageing population will have an impact on the efficiency and workload of emergency services and hospitals. Our health system needs to start getting ready to face this challenge." Ms Lewis says.

"An increase in demand for services will end up contributing to the escalating cost of non-beneficial intensive care or surgical treatments. Doing everything that is technically available for older people dying of natural causes is not necessarily appropriate and leads to inequities of access available to the rest of the general population."

Rather than persisting with care guidelines that have evolved out of top-down delegation of health policy and practice, Ms Lewis and her co-authors call for a community-based approach for terminal care services.

This would require better communication between medical staff and patients and between patients and their families to ensure expectations are met in palliative and supportive care.

"Much work remains in the area of increasing public awareness of the need to hold the conversations with their family and GP about what people consider unacceptable and what they are prepared to go through in the event of a health crisis when they cannot speak for themselves," says Ms Lewis.

The research authors also call for the development of planning tools for medical staff enabling them to identify earlier those people who are near the end of life and whose end-of-life care needs have not been articulated.

"We're working on improving shared decision-making to facilitate advance care planning," Ms Lewis says. "We hope that using these in routine clinical care may offer a valuable strategy to reduce both unnecessary hospitalisations and low-value care."

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Provided by University of New South Wales

More candor urged in care of dying cancer patients

14 feb 2011-- Patients don't want to hear that they're dying and doctors don't want to tell them. But new guidance for the nation's cancer specialists says they should be upfront and do it far sooner.

The American Society of Clinical Oncology says too often, patients aren't told about options like comfort care or even that their chemo has become futile until the bitter end.

To help families broach the topic, too, the group developed an easy-to-read booklet about those choices, from standard care to symptom relief, and advice about what to ask to maximize remaining time.

"This is not a 15-minute conversation, and it should not happen in the back of the ambulance on the way to the ICU at 3 in the morning," says ASCO chief executive Dr. Allen Lichter. "When everyone is well and has their wits about them, it's time to start the process."

The guidance and booklet - available at http://www.cancer.net - mark an unusually strong push for planning end-of-life care, in a profession that earns more from attacking tumors than from lengthy, emotional discussions about when it's time to stop.

"This is a clarion call for oncologists . to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness," the guidance stresses.

But it's part of a slowly growing movement to deal with a subject so taboo that Congress' attempt to give such planning a nudge in 2009 degenerated into charges of "death panels."

Now consider a program in Pittsburgh named Closure. In so-called "community conversations," the program teaches families how to talk with each other and their doctors about what they want - and want to avoid - in their final days. Created by the Jewish Healthcare Foundation, sessions have spread to hospitals, religious centers and neighborhoods around the city, and a website opened last month at http://www.closure.org .

The sessions are frank. Doctors tell of entering hospital rooms late at night asking for resuscitation preferences should a very ill patient worsen only to find relatives didn't know their loved one was that sick.

"There is going to be, over the next few years, a groundswell of people telling physicians, `I don't want to go out in excruciating pain, short of breath, alone, surrounded by lights and sirens and people pounding on my chest,'" predicts Dr. Jonathan Weinkle, a primary care physician who advises the program.

"Everybody wants a good death but not a moment too soon, but they don't have the language to ask for it."

Closure participant Pearl Moore, a retired Pittsburgh oncology nurse, urges people to start planning before they're ever sick, when it's easier to discuss.

Moore's mother died of stomach cancer without health workers or family ever discussing the inevitable. Haunted, she returned to college to specialize in cancer nursing. She helped her patients discuss quality of life, "to be able to live until they died, is the way I put it," Moore says.

And years ago she prepared her own living will and other health care directives, giving copies to her daughter, Cheryl, as soon as she was grown.

"Remembering my mother, we had the discussion," says Moore.

It's not clear how often the still healthy like Moore do that kind of advance planning.

But the oncology society says it isn't happening enough with the very sick. Fewer than 40 percent of advanced cancer patients have what it calls a "realistic conversation" with their doctors about what to expect and their choices of care.

The consequences: Patients increasingly are receiving aggressive chemotherapy in the last two weeks of life. They're spending more of their last months hospitalized. They're not told that a lot of expensive, side effect-prone therapies buy at best a few more months.

They think palliative care - specialized care for pain, nausea, shortness of breath - means giving up when it should be offered with standard anti-tumor care.

And they're not referred to hospice until their final days. Lichter tells of a lung cancer patient who spent his last days on a ventilator, unable to say goodbye and incurring $25,000 in hospital bills, because his family called 911 when he became short of breath. Hospice care could have eased that symptom at home.

The society plans by summer to issue detailed guidelines to help doctors conduct those tough conversations. Meanwhile, among its advice for patients:

-Ask your doctor about pros and cons of different treatment options, and discuss your priorities, including quality of life, with the doctor and family. You can change your mind later.

-Ask about palliative care for symptom relief along with your chemo. A major study last summer found that combination helped advanced lung cancer patients live a few months longer, because people who feel better can tolerate more anti-cancer treatment.

-A living will ensures health workers and family know your choices when you cannot communicate, including whether you would want such things as a feeding tube.

-Most clinical trials for experimental treatments won't admit people who've already undergone multiple treatments, so consider that option early.

More information:
Cancer group: http://www.cancer.net

Closure: http://www.closure.org

State advance directives: http://www.caringinfo.org/PlanningAhead

Not All Terminally Ill Receive Desired End-of-Life Care

Patients are more likely to receive preferred care after discussion with a physician

05 feb 2010-- Most terminally ill patients receive end-of-life care consistent with their stated preferences, and are more likely to receive the care they prefer if they have discussed their preferences with a physician, according to a study published online Feb. 1 in the Journal of Clinical Oncology.

Jennifer W. Mack, M.D., from the Dana-Farber Cancer Institute in Boston, and colleagues surveyed 325 patients with advanced cancer about their preferences for life-extending versus symptom-directed care and the actual end-of-life care they received.

The researchers found that 68 percent of patients received end-of-life care consistent with their preferences. However, 74 percent of patients who recognized that they were terminally ill received such care, and most preferred symptom-directed care. The 39 percent of patients who reported having discussed their end-of-life preferences with a physician were more likely to receive care consistent with their preferences (odds ratio, 2.26), particularly if they recognized that they were terminally ill (odds ratio, 3.94).

"Patients with cancer are more likely to receive end-of-life care that is consistent with their preferences when they have had the opportunity to discuss their wishes for end-of-life care with a physician," Mack and colleagues conclude.

Abstract
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Brown expert offers guide to end-of-life care

PROVIDENCE, R.I, 12 feb 2009--Years ago, dying patients in most communities often had a single option if they needed hospice care. Now they have many more; competition reigns.

This is one crucial reason why a Brown University researcher and end-of-life expert has helped develop user-friendly guides for both doctors and patients about the best hospice care options in the marketplace.

"While all hospice programs are very good, there are some programs that are really excellent," said Joan Teno, M.D., a professor of community health and medicine at the Warren Alpert Medical School of Brown University. "You want to choose the hospice program that is striving and achieving excellence in quality of care."

Teno's guide for doctors will be published in the Feb. 11 edition of the Journal of the American Medical Association. Her article, "Referring a Patient and Family to High-Quality Palliative Care at the Close of Life," is co-written with Stephen Connor, vice president for research and international development at the National Hospice and Palliative Care Organization.

Teno and Connor are at work on a user-friendly guide for patients and families that incorporates a portion of the JAMA article but with more streamlined language accessible to the general public.

Teno said she and Connor worked to synthesize existing literature on end-of-life, or palliative care with a simple goal. They wanted to create something easy to understand for both physicians and families who must choose between hospice or hospital-based end-of-life care.

Having such information at hand when a patient or family member is soon to die is increasingly important, Teno said, in large part because of heightened competition in the marketplace.

"And so we tried to define what you should expect," she said, "and define what high-quality care means at the close of life."

Overall, Teno said, she and Connor hoped to compile guidelines that addressed the three C's — whether care is "competitive, compassionate and coordinated."

For families, Teno and Connor are developing even simpler, easy-to read guidelines they've dubbed "The Five C's." They urge families to make sure a hospice or hospital palliative care program will provide:

• competent care by an interdisciplinary team;
• care centered on the patient and family needs;
• coordinated care that provides access to needed services;
• compassionate care; and
• care committed to quality.

Teno and Connor suggest families should make sure a hospice program is certified by a recognized national program, determine if a full-time medical director is on staff, and whether or not staff is available 24 hours a day, seven days a week.

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Editors: Brown University has a fiber link television studio available for domestic and international live and taped interviews, and maintains an ISDN line for radio interviews. For more information, call (401) 863-2476.

Seniors Tend to Stick With End-of-Life Care Preferences

By Alan Mozes
30 oct 2008- Regardless of declines in either mental or physical health, most senior citizens do not change their outlook on how they want their end-of-life care to be when the time comes, new research suggests.
The study notes, however, that despite observing an overall stability in patient perspective, certain patients do seem to change their mind over time.
"We found that the people who wanted the least [aggressive treatment] were the most likely to continue wanting the least, whereas the people wanting the most were the most likely to change over to wanting less over time," noted study author Dr. Marsha N. Wittink from the department of family medicine and community health at the University of Pennsylvania School of Medicine in Philadelphia.
Wittink and her team published the observations in the Oct. 27 issue of the Archives of Internal Medicine.
Their findings are based on a comparative analysis of two end-of-life treatment preference questionnaires completed by 818 physicians, all of whom graduated from Johns Hopkins University between 1948 and 1964.
At an average age of 69 when the study was launched, all the participants completed an initial survey in 1999, followed by a second survey in 2002.
At both times, the patients were asked to indicate which types of interventions they would want should they experience brain death that rendered them unable to either speak or recognize those around them. Possible interventions included surgery, insertion of a feeding tube, dialysis, and/or cardiopulmonary resuscitation.
Serious changes in the participants' physical and/or mental health over the course of the intervening three years were also monitored.
The research team found that the overall percentage of study participants who fell into each level of treatment preference --"aggressive," "intermediate" or "least aggressive"-- remained pretty constant over the three years, as patients who turned down particular treatments in 1999 continued to be likely to do so in 2002.
Specifically, while 12 percent, 26 percent and 62 percent respectively preferred aggressive, intermediate or least aggressive treatment in 1999, overall preferences had shifted only slightly by 2002: to 14 percent, 26 percent and 60 percent, respectively.
Getting older or experiencing a decline in either mental or physical health did not appear to impact patient preferences, the researchers noted.
However, although the absolute numbers of those choosing one type of treatment approach or another remained more or less constant, individuals didn't necessarily stay in their original category, with some gravitating towards more or less aggressive intervention over time.
For example, among those who had indicated that they wanted "aggressive" treatment in 1999, just 41 percent maintained that preference in 2002.
On the other hand, those who lacked either a living will or a durable power of attorney when they first outlined their preferences in 1999 were twice as likely to want "aggressive" life-sustaining care (as opposed to "least aggressive" care) when they were re-interviewed in 2002.
"This dynamic is important to understand, because even though most people are stable in their preferences -- which is not surprising -- some people are not," said Wittink. "So that means that both doctors and patients need to be thinking and communicating about patient feelings as preferences change."
Dr. Steven Pantilat, director of the palliative program at the University of California, San Francisco, suggested that the findings make intuitive sense.
"Previous research has actually suggested that people do change their minds, and that it's hard to predict whether an individual will end up wanting more or less aggressive treatment down the road," he said. "But even though this finding is a little different than what the prior literature has indicated, I have to say that it's more in line with what I've personally observed. Which reflects the fact that generally people's values and goals don't change that much over time."
"I also think that moving from wanting more treatment to wanting less is typical of many patients," he said. "Because as seriously ill people experience the increasing burden of treatment coupled with what they realistically can expect to get from it, there is often a shift in focus towards gaining comfort and a better quality of life, and away from aggressive life-prolonging intervention."
"Whatever the case, what's important is that patients are upfront at an early stage about their preferences, so they get the care they want," he stressed. "Because preferences about end-of-life are not whims. And if you don't express yourself you may very well get the kind of care you don't want."
More information
For more on end-of-life directives, visit the American Academy of Family Physicians.

Discussing End-of-Life Care May Improve Quality of the Life That's Left

By Todd Neale

BOSTON, 19 oct 2008--Discussions about end-of-life care appear to benefit terminally ill cancer patients and their caregivers alike, researchers here found. Cancer patients who spoke with their physicians about their expectations for medical care near death did not have higher rates of depression or anxiety and were less likely to receive aggressive medical care compared with patients who did not have such discussions, Alexi Wright, M.D., of Dana-Farber Cancer Institute, and colleagues reported in the Oct. 8 issue of the Journal of the American Medical Association. More aggressive medical care in the week before death was associated with worse patient quality of life (P=0.01) and a higher risk of major depressive disorder among caregivers (OR 3.37, 95% CI 1.12 to 10.13), the researchers said.
They also found that patients who had discussed end-of-life issues enrolled earlier in hospice care, which was associated with improved patient quality of life (P=0.01); that, in turn, was associated with improved quality of life for caregivers after the patient had died (P=0.001).
"Given the adverse outcomes associated with not having end-of-life discussions," the researchers said, "there appears to be a need to increase the frequency of these conversations. By acknowledging that death is near, patients, caregivers, and physicians can focus on clarifying patients' priorities and improving pain and symptom management."
Although it has been suggested that discussing end-of-life issues may cause psychological distress in patients as they near death, no studies have examined the issue, according to the researchers.
So they prospectively evaluated 332 terminally ill cancer patients (mean age 57.9; 55.1% male) and their caregivers at seven U.S. centers until a median of 6.5 months after the patients had died. The patients were participating in the Coping with Cancer study.
Patients lived for a median of 4.4 months after study enrollment.
Overall, 123 (37%) of the patients reported having a discussion about end-of-life care with their physicians.
Those patients did not have an increased risk of major depressive disorder (OR 1.33, 95% CI 0.54 to 3.32), generalized anxiety disorder (OR 2.50, 95% CI 0.51 to 12.1), or other mental disorders compared with patients who did not have an end-of-life conversation with their physicians.
Patients who had talked about end-of-life care were more likely to accept that their illness was terminal (52.9% versus 28.7%), to prefer treatment for easing pain rather than extending life (85.4% versus 70%), and to have completed a do-not-resuscitate order (63% versus 28.5%). All were significant at P<0.001. p="0.01)," p="0.004)," p="0.02)," p="0.04)," p="0.001)" p="0.002)">

Primary source: Journal of the American Medical AssociationSource reference:Wright A, et al "Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment" JAMA 2008; 300: 1665-1673.

Most cancer doctors avoid saying it's the end

By MARILYNN MARCHIONE
16 june 2008--One look at Eileen Mulligan lying soberly on the exam table and Dr. John Marshall knew the time for the Big Talk had arrived.
He began gently. The chemotherapy is not helping. The cancer is advanced. There are no good options left to try. It would be good to look into hospice care.
"At first I was really shocked. But after, I thought it was a really good way of handling a situation like that," said Mulligan, who now is making a "bucket list" — things to do before she dies. Top priority: getting her busy sons to come for a weekend at her Washington, D.C., home.
Many people do not get such straight talk from doctors, who often think they are doing patients a favor by keeping hope alive.
New research shows they are wrong.
Only one-third of terminally ill cancer patients in a new, federally funded study said their doctors had discussed end-of-life care.
Surprisingly, patients who had these talks were no more likely to become depressed than those who did not, the study found. They were less likely to spend their final days in hospitals, tethered to machines. They avoided costly, futile care. And their loved ones were more at peace after they died.
Convinced of such benefits and that patients have a right to know, the California Assembly just passed a bill to require that health care providers give complete answers to dying patients who ask about their options. The bill now goes to the state Senate.
Some doctors' groups are fighting the bill, saying it interferes with medical practice. But at an American Society of Clinical Oncology conference in Chicago earlier this month, where the federally funded study was presented, the society's president said she was upset at its finding that most doctors were not having honest talks.
"That is distressing if it's true. It says we have a lot of homework to do," said Dr. Nancy Davidson, a cancer specialist at Johns Hopkins University in Baltimore.
Doctors mistakenly fear that frank conversations will harm patients, said Barbara Coombs Lee, president of the advocacy group Compassionate Choices.
"Boiled down, it's 'Talking about dying will kill you,'" she said. In reality, "people crave these conversations, because without a full and candid discussion of what they're up against and what their options are, they feel abandoned and forlorn, as though they have to face this alone. No one is willing to talk about it."
The new study is the first to look at what happens to patients if they are or are not asked what kind of care they'd like to receive if they were dying, said lead researcher Dr. Alexi Wright of the Dana-Farber Cancer Institute in Boston.
It involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year. They were interviewed at the start of the study and are being followed until their deaths. Records were used to document their care.
Of the 323 who have died so far, those who had end-of-life talks were three times less likely to spend their final week in intensive care, four times less likely to be on breathing machines, and six times less likely to be resuscitated.
About 7 percent of all patients in the study developed depression. Feeling nervous or worried was no more common among those who had end-of-life talks than those who did not.
That rings true, said Marshall, who is Mulligan's doctor at Georgetown University's Lombardi Comprehensive Cancer Center. Patients often are relieved, and can plan for a "good death" and make decisions, such as do-not-resuscitate orders.
"It's sad, and it's not good news, but you can see the tension begin to fall" as soon as the patient and the family come to grips with a situation they may have suspected but were afraid to bring up, he said.
From an ethics point of view, "it's easy — patients ought to know," said Dr. Anthony Lee Back of the Fred Hutchinson Cancer Center in Seattle. "Talking about prognosis is where the rubber meets the road. It's a make-or-break moment — you earn that trust or you blow it," he told doctors at a training session at the cancer conference on how to break bad news.
People react differently, though, said Dr. James Vredenburgh, a brain tumor specialist at Duke University.
"There are patients who want to talk about death and dying when I first meet them, before I ever treat them. There's other people who never will talk about it," he said.
"Most patients know in their heart" that the situation is grim, "but people have an amazing capacity to deny or just keep fighting. For a majority of patients it's a relief to know and to just be able to talk about it," he said.
Sometimes it's doctors who have trouble accepting that the end is near, or think they've failed the patient unless they keep trying to beat the disease, said Dr. Otis Brawley, chief medical officer at the American Cancer Society.
"I had seven patients die in one week once," Brawley said. "I actually had some personal regrets in some patients where I did not stop treatment and in retrospect, I think I should have."
James Rogers, 67 of Durham, N.C., wants no such regrets. Diagnosed with advanced lung cancer last October, he had only one question for the doctor who recommended treatment.
"I said 'Can you get rid of it?' She said 'no,'" and he decided to simply enjoy his final days with the help of the hospice staff at Duke.
"I like being told what my health condition is. I don't like beating around the bush," he said. "We all have to die. I've had a very good life. Death is not something that was fearful to me."

In New York City, Two Versions of End-of-Life Care

By ANEMONA HARTOCOLLIS
01 jun 2008--There are two starkly different paths toward death in New York City’s hospitals, one for patients at elite private institutions, another for those at public hospitals, according to new data compiled as part of a consumer rating system.
Most elderly patients in their last two years of life have more intensive treatment, more tests, more days of hospitalization — and more out-of-pocket costs — at private teaching hospitals like N.Y.U. and Lenox Hill than their counterparts at Bellevue and the city’s other municipal hospitals, which have historically served the neediest New Yorkers.
The city’s private hospitals were among the most aggressive of about 3,000 hospitals studied across the nation, ranking in the 94th percentile as a group, while the public hospitals landed in the 69th percentile, still significantly above the national average.
The rankings, compiled by Consumer Reports from a 15-year research project based at Dartmouth College, have huge implications for administrators, doctors and patients as they consider which model of care is best for those suffering from chronic, fatal illnesses like cancer, congestive heart failure, lung disease and dementia.
The study does not address the question of whether longer stays and more intervention prolong patients’ lives, and the Dartmouth researchers argue, in general, that less-aggressive treatment does not change the outcome, but spares patients the agony of unnecessary tests and reduces the risk of hospital-borne infections.
“The general principle is that greater intensity of care is not better, and at the high end can actually be harmful,” Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, as the database is called, said in an interview on Thursday. Saying that New York’s healthcare system was “full of ironies,” Dr. Goodman suggested that the dichotomy of treatment might illustrate how a city with an abundance of sophisticated doctors and wide disparities in patients’ income and education could result in unfair distribution of resources.
“You have some of the most expensive and high-intensive care in the nation, and yet we know that there are populations that are not getting the care that they need,” Dr. Goodman said. “So this robs it, drains resources from places where it’s really necessary.”
The level of care was most intensive at New York University Medical Center, on First Avenue in the 30s in Manhattan, where 65 percent of patients saw 10 or more physicians in their last six months of life and paid an average of $5,500 beyond what Medicare — the federal insurance program for the elderly — pays for in the last two years of life. N.Y.U. ranked in the 99th percentile nationally.
In contrast, at Bellevue Hospital Center, on First Avenue in the 20s, 7 percent of patients saw 10 or more physicians, and patients averaged $1,380 in out-of-pocket expenses.
Dr. Elliott Fisher, another co-author of the Dartmouth Atlas, said that some people, but not all, were eager for every possible intervention to delay death. “Many patients say, ‘If I’m 85 and this is a choice between being in the hospital and being at home, I’d rather be home,’” he explained.
Kenneth Raske, president of the Greater New York Hospital Association, which includes public and private institutions, said the data was flawed because it worked backward from patients who died, rather than looking at the outcomes for patients who had the same treatment but survived.
He attributed the aggressiveness of private hospitals in New York simply to the sophistication of the patients and their families and the desire of doctors to give them the best possible care.
“The patients and physicians and their families, of course, are trying to live longer and beat whatever malady they have,” Mr. Raske said, “and that’s a reflection of the New York culture that we have.”
Dr. Eric Manheimer, who is the medical director at Bellevue and on the faculty at N.Y.U., said that having a foot in both the public and private systems gave him a unique perspective on the discrepancies. He said that care was less aggressive at public hospitals because most of their doctors — he estimated 75 to 85 percent — were salaried physicians with little financial incentive to order tests or other interventions. At private hospitals, he said, supply can create its own demand: There is often an abundance of beds and an endless list of specialists who can be called.
“You end up with the phenomenon of specialists referring to other specialists, with nobody coordinating, which results in confused messages, more referrals, more hospitalizations, deterioration in health care and a more anxious patient,” Dr. Manheimer said.
The city’s public hospitals, he said, offered a more collegial, intimate culture of care because many of their staff members came from the same community as their patients.
“We’re not smarter or better than the private doctors,” Dr. Manheimer said. “But when you have a salaried physician staff that’s cohesive, that works together, with no incentive to do additional health care, that’s a different mental model.”
He noted that the Mayo Clinic in Rochester, Minn., a prestigious private hospital where doctors also work on salary, ranked in the 28th percentile for aggressiveness of care.
The Dartmouth Atlas, from which the data is drawn, includes 46 New York City hospitals: 8 public and 38 private.
The Consumer Reports rankings allow consumers to look at data from hospitals across the country, and examine the intensity of care during the last two years of life. Intensity is measured by how many days the average patient spent in the hospital, how many times a doctor visited that patient and how much the patient or private insurer spent for doctors beyond what Medicare covered.
Patients in the city’s private hospitals averaged 54 visits from doctors, while those in public hospitals averaged 24 visits during the final six months. In private hospitals, 56 percent of patients saw 10 or more physicians, compared with 32 percent in public hospitals.
And private patients paid an average of $4,000 out-of-pocket over two years, nearly double the $2,200 per patient at the city-run institutions. But in terms of the ultimate outcome, there was little difference.
The Dartmouth Atlas showed that 58 percent of the public-hospital patients died in the hospital as opposed to at home or in hospice care, compared with 57 percent for private hospitals. Thirty percent of patients in public hospitals had been admitted to intensive care units before their death, compared with 27 percent in private hospitals.
Many fewer patients from public hospitals — 7 percent — were enrolled in a hospice than patients from private hospitals, where the rate was 12 percent, according to the Dartmouth data.

Care of Dying Is Outlined by W.H.O.

By DONALD G. McNEIL Jr.
Saying that “everyone has the right to be treated, and die, with dignity,” the World Health Organization yesterday issued its first guide to planning end-of-life care.
The 51-page document was aimed not at individual doctors, but at national health ministers, said one of its authors, Dr. Cecilia Sepúlveda, palliative care expert with the health organization.
It contains formulas for calculating how many people in a country are in need of such care.
It also outlines typical obstacles to providing it: national laws that make it hard for pharmacists to stock powerful painkillers, lack of training for doctors and nurses, and fears of addiction on the part of patients.
It also cites countries that offer good end-of-life care despite national poverty — mostly by having it done at home, by relatives given modest amounts of training.
The “most impressive” programs that Dr. Sepúlveda said she had found were in Uganda and in the state of Kerala in India. In both places, political leaders and medical doctors had combined their efforts.
In 2005, more than seven million people died of cancer, and 70 percent of them were in poor or middle-income countries where there was little money for diagnosis or treatment, the health organization report said. Unless a cure is found for cancer, more than 11 million people will die of it each year by 2030.
Although the report was initially written for countries preparing national cancer plans, it is also useful in countries with many people dying of AIDS or experiencing any other slow, painful death, Dr. Sepúlveda said.