Researchers looking at the care received by patients with non-small cell lung cancer (NSCLC) in the United States and in Ontario, Canada, during their last 5 months of life found large differences between the two countries. For example, patients in the United States were more likely to receive chemotherapy in the months before death, and patients in Ontario were more likely to die in a hospital. Dr. Joan Warren and her colleagues in NCI's Division of Cancer Control and Population Sciences collaborated with a group of investigators in Ontario to compare end-of-life care for elderly patients. These findings appeared online May 18 in the Journal of the National Cancer Institute.
The researchers used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and from several linked databases in Ontario, the most populous Canadian province. The study included 13,533 patients from the United States and 8,100 patients from Ontario, all of whom had been diagnosed with NSCLC and died of cancer at age 65 or older between 1999 and 2003.
After adjusting for demographic differences in the two populations, the researchers found substantial differences in patterns of care near the end of life. In addition to differences in chemotherapy use and place of death, the researchers found that the majority of U.S. patients used hospice care in the last months of life. No formal hospice programs exist in Ontario, which instead provides palliative care in the home, in outpatient clinics, and in hospitals.
For patients in both countries, the use of emergency room services and hospitalization rose near the time of death. But during the last 30 days of life, 12 percent fewer U.S. patients visited an emergency room compared with those in Ontario. And fewer U.S. patients were admitted to the hospital during the last 30 days of life.
More than 60 percent of patients in Ontario who were hospitalized during the last month of life received palliative care as an inpatient, with over 80 percent of the hospitalized Ontario patients dying in the hospital. "It appears that most [of these patients] were admitted for supportive care," wrote the authors. About the same percentage of U.S. patients were in hospice during their last month of life, allowing them to die outside of the hospital.
"Despite relatively high use of community supportive care, the rates of inpatient death are too high in the United States and much too high in Ontario," wrote Dr. David Goodman of the Dartmouth Medical School in an accompanying editorial. But he cautions against expanding enrollment in hospice programs blindly without attention to the wishes of individual patients. Currently, he concluded, patients in both countries "do not yet adequately participate in end-of-life care decisions."
NCI Cancer Bulletin for May 31, 2011 - National Cancer Institute
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