Nearly one of every three Americans on Medicare undergoes surgery in their last year of life, according to a new study. Those numbers are leading experts to question whether these costly and invasive procedures are the right prescription for dying patients and a bloated health care system.
The study, published in The Lancet, analyzed more than 1.8 million claims for Medicare patients who died in 2008, and found that 32 percent of them had an operation in the year before they died. Nearly one in five had a surgical procedure in the last month of life and one in 10 went under the knife in the last week of life.
Dr. Ashish Jha, the study's author and an associate professor of health policy at the Harvard School of Public Health, said it's well known that patients receive lots of health care at the end of their lives, but this study is the first to show how many of them are getting costly, invasive surgery, and then dying.
"This level of surgical intensity doesn't seem to be having much in the way of benefit for the population," Jha said. "Our sense is that there are probably lots of unnecessary procedures that go on at end of life."
The study found that a patient's likelihood of getting surgery varied greatly depending on their age and where they lived. Surgery was more common for 65-year-olds than for patients in their 80s and 90s. Operations also became more likely in regions with greater availability of hospital beds and higher levels of Medicare spending.
All this surgery didn't necessarily prolong life. Areas where doctors did lots of operations had higher patient death rates.
Ken Thorpe, a professor of health policy at Emory University, said doctors and health care systems should reevaluate the kinds of interventions they give to patients who may not live long enough to really benefit from their treatments.
"Researchers are finding that these aggressive procedures have the same outcomes as less invasive, less expensive treatments," he said. "This study shows us there's an enormous opportunity to basically save money and provide less intervention, and still have the same quality of care and life expectancy."
The study also suggests that more dying people have surgery not because they want it or need it to save their lives, but because American medical culture encourages aggressive care like surgery, even at the end of a patient's life.
Dr. Frank Opelka, the associate medical director for the American College of Surgeons, said a doctor's knee-jerk reaction is to do anything possible to prolong a patient's life or ease suffering. And it's often not clear whether a patient will live or die until the final weeks and days of their life.
"Sometimes, it's just impossible to tell whether a treatment or surgery will be futile or not," Opelka said. "But you're going to operate, hoping for the best."
Jha said it's impossible to tell from the Medicare claims analyzed in the study whether surgery was really necessary or whether patients and their families wanted an operation. But he said it underscores a general hesitation by doctors to discuss a difficult subject with their patients: that they might die.
"A lot of physicians struggle to talk about prognosis, whether people are going to live or die. Instead they focus on trying to make little things better," Jha said. "Some of these procedures are a distraction from what might really be important for patients, like being able to spend time with family, being able to say goodbye to people they love, or what their quality of life will look like."
Experts say this study highlights the need for doctors and patients to talk about palliative care options as well as more aggressive treatments like surgery.
"We need to provide patients options for how aggressive they want to be toward the end of life," Thorpe said.