Quality over quantity. As people get older, their health care goals may shift away from living as long as possible to maintaining a good quality of life. In key areas, however, the medical treatment older people receive聽often doesn鈥檛 reflect this change, according to a new study.
The from the Dartmouth Atlas Project聽uses Medicare claims data to examine聽aging Americans鈥 health care. Among other things, it identified five key areas where too many older people continue to receive treatments that don鈥檛 meet established聽guidelines or, often, their own goals and preferences.
Two of the five have to do with preventive care that may not benefit seniors: screening for breast and prostate cancer. The other three address care at the end of life: late referral to hospice care, time in the intensive care unit in the last six months of life and placing feeding tubes in patients with dementia.
While the measures themselves are quite different, they each highlight the need for better communication and shared decision-making among patients, their families and their medical providers.
鈥淲here there are harms and benefits and people judge them differently, that鈥檚 where the shared decision-making comes in,鈥 said Dr. Julie Bynum, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.
Despite the simplicity of聽a mammogram or a blood test to check for prostate cancer, if the screening聽is positive for cancer, that can set off a cascade of further testing and treatment. Those efforts , whose health may be fragile or who have multiple medical conditions.
In addition, older people may well die from something else before a cancer progresses, said Dr. Richard Wender, chief cancer control officer at the American Cancer Society.
“The single hardest concept for the public to understand is the natural history of finding a cancer through a screening process,鈥 Wender said. 鈥淢any people have the sense that had it not been found that cancer would have threatened their life within a couple of years or maybe even a couple of months.”
Experts have cautioned older patients about both tests.聽The U.S. Preventive Services Task Force, an independent panel that weighs evidence and makes recommendations about prevention services, has at any age聽and said that there’s to know whether women benefit or risk harm by undergoing breast cancer screening after age 74.
Still, the Dartmouth Atlas analysis found that 20 percent of male Medicare beneficiaries age 75 and older got a PSA test to screen for prostate cancer in 2012, and 24 percent of female beneficiaries that age had a mammogram to screen for breast cancer that year.
Guidelines aside, clinicians and their patients need to discuss the pros and cons of testing and make a decision based on the patient鈥檚 values and preferences, experts say.
For example, a 75-year-old woman who is willing to accept that she might actually die of breast cancer within聽10 years but wants to avoid the anxiety and harms of treatment, might choose not to be tested.
鈥淚 ask people, 鈥楧o you think you鈥檙e going to be around in 10 years? Help me decide鈥 whether to order a mammogram,鈥 said Bynum, whose work focuses on geriatrics.
As people near the end of their lives, it鈥檚 especially important for patients and their family members to discuss their goals and wishes with clinicians. Patients often want to be kept comfortable rather than undergo medical interventions, but physicians and nurses are still trained to do everything possible to prevent death, said Dr. Diane Meier, director of the Center to Advance Palliative Care and professor of geriatrics at Mount Sinai鈥檚 Icahn School of Medicine in New York.
The three end-of-life criteria that the Dartmouth researchers cited are areas that geriatrics experts agree are critical but have proven difficult to get providers, health systems and the general public to accept, said Bynum.聽Late referral to hospice and spending聽time in a hospital intensive care unit can adversely affect terminal patients’ health, result in higher costs and run counter to their hope for a peaceful death. Feeding tubes in patients with advanced dementia can lead to other complications.
The Dartmouth study found that in 2012, 17 percent of Medicare beneficiaries who died were enrolled in hospice only during the last three days of life. Medicare, however, will approve hospice benefits, which generally include comfort care rather than curative treatment, when the physician certifies that someone is expected to live for no more than six months.
The study also found that people spent an average of nearly four days in intensive care during the last six months of life, a figure that is trending upward.
Finally, even though it doesn鈥檛 prolong their lives to place feeding tubes in patients with dementia, who naturally lose interest in food and their ability to swallow in the final stages of the disease, 6 percent of Medicare beneficiaries with dementia received them in their last six months of life in 2012.
Communication is key, but the skills that are needed to counsel patients aren鈥檛 being taught, said Meier.
鈥淚f you unleash an oncologist who does not know how to say, 鈥榊our cancer has progressed,鈥 but they know how to say, 鈥淚 know what we can try,鈥 that鈥檚 why people end up in the ICU and with feeding tubes鈥 at the end of life, she said. 鈥淚t鈥檚 easier than having a difficult conversation.鈥
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