Reducing Cancer Care Costs: Oncologists Need to Get a Grip on Reality, and Talk about Dying
We’ve reached the second half of our discussion on Bending the Cost Curve in Cancer Care. The authors of the NEJM paper, Drs. T. Smith and B. Hillner, go on to consider how doctors’ behavior influences costs in Changing Attitudes and Practice. Today’s point on the list: “Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.”
In other words (theirs): “The first step is a frank acknowledgment that changes are needed.” A bit AA-ish, but fair enough –
The authors talk about needed, frank discussions between doctors and patients. They emphasize that oncologists/docs drive up costs and provide poorer care by failing to talk with patients about the possibility of death, end-of-life care, and transitions in the focus of care from curative intent to palliation.
They review published findings on the topic:
In a study at our institution of 75 hospitalized patients with cancer, the oncologist had initiated a discussion of advance directives with only 2 patients.31 In a prospective, multicenter study of 360 patients, only 37% of the patients and their families could recall having a discussion about impending death with the physician.32 Such a discussion is a prerequisite to good planning. Oncologists wait until symptoms appear or until they believe that nothing more can be done.33 In one study, at 2 months before their death, half the patients with metastatic lung cancer had not had a discussion with their doctors about hospice.34 This may explain why in a recent series the average length of stay in hospice for patients with lung cancer was 4 days.35
Although I have questions about the specific methods for some of these references, the bottom line is clear: Oncologists wait too long to talk with their patients about palliative or hospice care.
What they’re saying is that doctors need to get a grip on the problem (to overcome their denial and inability to talk about death), if they want to help patients come to terms with the inevitable. Doing so would save billions each year in the US, and would also spare patients from futile treatments and needless suffering.
I couldn’t agree more. It’s a potential win/win, if physicians think realistically about the situation and possible outcomes, and speak openly – and gently, no matter what, with their patients.
—
Related Posts:
2 Comments
Leave a Reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Dear Elaine,
Thank you for championing a rich discussion on the need for better communication with seriously I’ll patients. I am one of those patients as well as being a healthcare professional and senior program officer for a large health foundation. I blog about my encounters with the health care delivery system on the blog healthAGEnda at http://www.jhartfound.org/blog. In addition to communications as a barrier I would add that many patients believe that more is better. They don’t necessarily understand that if they are not in curative mode that they might be giving up the remaining quality of life without later benefit. I have chosen the palliative approach and would welcome your comments on the blog.
All best, Amy
Dear Amy,
Thanks so much for sharing your thoughts here. Indeed, I’ve seen and admired your thoughtful writing. I’m not sure I was aware of the blog on the John A. Hartford Foundation’s site, so I appreciate your pointing it out to me and my readers. With best wishes, Elaine