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At the end of life, who decides where patients die?

John Kinney, 75, who has lung cancer, lives in Tampa with his daughter Kate Tomey. He was given one to two years to live.


John Kinney, 75, who has lung cancer, lives in Tampa with his daughter Kate Tomey. He was given one to two years to live.

Whether older cancer patients die in hospitals hooked up to machines or at home surrounded by family has more to do with hospital practices and geography than what the patient actually wants, a study released this week has found.

Nearly one-third of patients over 65 with advanced cancer died in a hospital, according to a study by the Dartmouth Atlas Group, a leading authority on the U.S. health care system. Many received in their final weeks intensive treatments like chemotherapy and intubation that weren't going to change their odds and may have affected the quality of their final days.

"Patients often unnecessarily receive care in intensive care units and invasive procedures," said lead author Dr. David Goodman. "On average, patients, particularly with advanced cancer, would much prefer to receive care that allows them the highest quality of life in their last weeks and months — and care that allows them to be whenever possible at home and with their family."

Hospitals in the Tampa Bay area got better-than-average marks from the Dartmouth Atlas Project, whose research received significant attention during the debate on health care reform. In Tampa, 24 percent of cancer patients on Medicare, the government insurance plan for retirees, die in a hospital, compared with 35 percent in Miami. Some of the most intensive care occurred in Manhattan, where 47 percent of cancer patients on Medicare died in hospitals.

The health policy group, which is affiliated with Dartmouth College in New Hampshire, examined a representative sample of records from Medicare patients who died between 2003 and 2007. Most of the half-million Americans who die of cancer annually are over 65.

Goodman said treatment patterns have evolved more by accident than by design. Simply put, regions that have a lot of intensive care units tend to use them. Those with strong hospice programs steer patients there.

"The care patients receive has less to do with care they want and more to do with the hospital they happen to seek care from," he said.

• • •

Physicians also have a hard time telling patients that a cure is unlikely, Goodman noted. Their focus is fighting disease. But as a cancer becomes terminal, many doctors struggle to speak honestly about the odds and how treatment affects quality of life.

John Kinney was told that his wife had a fighting chance against breast cancer — right up until he was told she would die in two days. Then he was diagnosed with lung cancer.

"I appreciated the doctor telling me you have lung cancer and it's going to kill you and we can't do anything about it," said Kinney, 75, who was given one to two years to live.

That was over a year ago. He received chemotherapy at Moffitt Cancer Center in Tampa to slow the cancer's progression and has undergone radiation to relieve pain. Moffitt doctors discussed hospice services with him.

Now he is living at his daughter's South Tampa home, where caregivers from LifePath Hospice in Hillsborough County check on him weekly and are a phone call away if they are needed.

Kinney says he's living a good life, enjoying pleasures like watching college football. His daughter, Kate Tomey, takes him out for ice cream and dinners at Outback Steakhouse. He can shower by himself and occasionally takes a short walk.

He hopes to stay at home as long as he isn't a burden to his family; at that point, he can go to a hospice facility. Kinney doesn't want intensive hospital care.

"I really can't get excited over dying. I had a good life," said Kinney, who had four children, three of whom are living, and careers as a state trooper, schoolteacher and corrections officer, among other jobs. "I'm kind of interested to see what's on the other side."

Many cancer patients share his attitude, researchers said. But end-of-life practices at the nation's hospitals range widely. Moffitt hospitalized half of the Medicare patients studied during their final month of life, the report noted. By comparison, two Detroit hospitals admitted three-fourths of their patients.

Both Moffitt and Tampa General Hospital, also included in the report, performed better than the national average on several key indicators measuring aggressiveness of end-of-life care. Other local hospitals' patient numbers weren't large enough to be included in the report, but generally, it found Medicare patients in Clearwater and Tampa were slightly less likely to die in hospitals than were patients in St. Petersburg.

• • •

Dr. Lodovico Balducci, who leads Moffitt's senior adult oncology program, said he speaks with cancer patients about treatment preferences as early as possible.

It's a delicate talk, so he teams up with a social worker. Then the focus turns to fighting the disease. But when it's clear treatments cannot save them, Balducci talks openly about their future and hospice referral.

"In 95 percent of the situations, people feel so much more relaxed and satisfied when they can face'' death, he said. "I tell them that death is a very important aspect of life."

At Moffitt, about two-thirds of patients enroll in hospice during the last month of their lives, the report found. That compares to about half of patients nationally.

Tampa General reported similar hospice numbers to Moffitt, which leaders say speaks to the strength of the region's hospice programs. TGH's palliative care team spends a lot of time with patients and families reviewing treatment choices.

"The goal of palliative care is discussing options," said Dr. Vince Perron, TGH's associate chief medical officer. "It's never to sway a patient or family to make a decision one way or another, but you certainly want them to make an informed decision."

Letitia Stein can be reached at or (813) 226-3322. For more health news, visit

At the end of life, who decides where patients die? 11/18/10 [Last modified: Thursday, November 18, 2010 11:01pm]
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