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Associations With End-of-Life Conversations

Baohui Zhang, MS; Alexi A. Wright, MD; Haiden A. Huskamp, PhD; Matthew E. Nilsson, BS; Matthew L. Maciejewski, PhD; Craig C. Earle, MD; Susan D. Block, MD; Paul K. Maciejewski, PhD; Holly G. Prigerson, PhD

Arch Intern Med. 2009;169(5):480-488.

Background  Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions.

Methods  Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases.

Results  Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = –0.17, P =.006).

Conclusions  Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Author Affiliations: Center for Psycho-Oncology and Palliative Care Research (Ms Zhang, Mr Nilsson, and Drs Block and Prigerson) and Departments of Medical Oncology (Drs Wright and Earle) and Population Sciences (Dr Earle), Dana-Farber Cancer Institute, Department of Health Care Policy (Dr Huskamp) and Center for Palliative Care (Drs Block and Prigerson), Harvard Medical School, and Department of Psychiatry, Brigham and Women's Hospital (Drs Block and Prigerson), Boston, Massachusetts; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, and Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill (Dr M. L. Maciejewski); and Department of Psychiatry, Women's Health Research, and Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, Connecticut (Dr P. K. Maciejewski).

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