Nearly 1 in 3 Medicare
patients undergo an operation in their final year of life.
By Liz Szabo
FEBRUARY 28, 2018
At 87,
Maxine Stanich cared more about improving the quality of her life than
prolonging it.
She
suffered from a long list of health problems, including heart failure and
chronic lung disease that could leave her gasping for breath.
When
her time came, she wanted to die a natural death, Stanich told her daughter,
and signed a “do not resuscitate” directive, or DNR, ordering doctors not to
revive her should her heart stop.
Yet a
trip to a San Francisco emergency room for shortness of breath in 2008 led
Stanich to get a defibrillator implanted in her chest — a medical device to
keep her alive by delivering a powerful shock. At the time, Stanich didn’t
fully grasp what she had agreed to, even though she signed a document granting
permission for the procedure, said her daughter, Susan Giaquinto.
That
clarity came only during a subsequent visit to a different hospital, when a
surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin
chest. To Stanich’s horror, the ER doctor explained that the device would not
allow her to slip away painlessly and that the jolt would be “so strong that it
will knock her across the room,” said Giaquinto, who accompanied her mother on
both hospital trips.
Surgery
like this has become all too common among those near the end of life, experts
say. Nearly 1 in 3 Medicare patients undergo
an operation in the year before they die, even though the evidence shows that
many are more likely to be harmed than to benefit from it.
The
practice is driven by financial incentives that reward doctors for doing
procedures, as well as a medical culture in which patients and doctors are
reluctant to talk about how surgical interventions should be prescribed more
judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she
sought care at the second hospital.
“We
have a culture that believes in very aggressive care,” said Redberg, who at the
University of California-San Francisco specializes in heart disease in women.
“We are often not considering the chance of benefit and chance of harm, and how
that changes when you get older. We also fail to have conversations about what
patients value most.”
While
surgery is typically lifesaving for younger people, operating on frail, older
patients rarely helps them live longer or returns the quality of life they once
enjoyed, according to a 2016 paper in Annals of Surgery.
The
cost of these surgeries — typically paid for by Medicare, the government health
insurance program for people over 65 — involve more than money, said Dr. Amber
Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical
Practice. Older patients who undergo surgery within a year of death spent 50
percent more time in the hospital than others, and nearly twice as many days in
intensive care.
And
while some robust octogenarians have many years ahead of them, studies show
that surgery is also common among those who are far more frail.
Eighteen
percent of Medicare patients have surgery in their final month of life and 8
percent in their final week, according to a 2011 study in The Lancet.
More
than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant
about 158,000 of the devices each year, according to the American College of
Cardiology. The total cost of the
procedure runs about $60,000.
Procedures
performed in the elderly range from major operations that require lengthy
recoveries to relatively minor surgery performed in a doctor’s office, such as
the removal of nonfatal skin cancers, that would likely never cause any
problems.
Research led by Dr.
Eleni Linos has shown that people with limited life expectancies are treated
for nonfatal skin cancers as aggressively as younger patients. Among patients
with a nonfatal skin cancer and a limited time to live, 70 percent underwent
surgery, according to her 2013 study in JAMA Internal Medicine.
When
Less Is More
Surgery
poses serious risks for older people, who weather anesthesia poorly and whose
skin takes longer to heal. Among seniors who undergo urgent or emergency
abdominal surgery, 20 percent die within 30 days, studies show.
With
diminished mental acuity and an old-fashioned respect for the medical
profession, some aging patients are vulnerable to unwanted interventions.
Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto
said. Many people of Stanich’s generation “thought doctors were God … They
never questioned doctors — ever.”
According
to the University of Michigan’s National Poll on Healthy Aging,
published Wednesday, more than half of adults ages 50 to 80 said doctors often
recommend unnecessary tests, medications or procedures. Yet half of those who’d
been told they needed an X-ray or other test — but weren’t sure they needed it
— went on to have the procedure anyway.
Dr.
Margaret Schwarze, a surgeon and associate professor at the University of
Wisconsin School of Medicine and Public Health, said that older patients often
don’t feel the financial pain of surgery because insurance pays most of the
cost.
When a
surgeon offers to “fix” the heart valve in a person with multiple diseases, for
example, the patient may assume that surgery will fix all of her medical problems, Schwarze
said. “With older patients with lots of chronic illnesses, we’re not really
fixing anything.”
Even as
a doctor, Redberg said, she struggles to prevent other doctors from performing
too many procedures on her 92-year-old mother, Mae, who lives in New York City.
Redberg
said doctors recently treated her mother for melanoma — the most serious type
of skin cancer. After the cancer was removed from her leg, Redberg’s mother was
urged by a doctor to undergo an additional surgery to cut away more tissue and
nearby lymph nodes, which can harbor cancerous cells.
“Every
time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg
said. And “Medicare would have been happy to pay for it.”
But her
mother often has problems with wounds healing, she said, and recovery would likely
have taken three months. When Redberg pressed a surgeon about the benefits, he
said the procedure could reduce the chances of cancer coming back within three
to five years.
Redberg
said her mother laughed and said, “I’m not interested in doing something that
will help me in three to five years. I doubt I’ll be here.”
Finding
Solutions
The
momentum of hospital care can make people feel as if they’re on a moving train
and can’t jump off.
The
rush of medical decisions “doesn’t allow time to deliberate or consider the
patients’ overall health or what their goals and values might be,” said Dr.
Jacqueline Kruser, an instructor in pulmonary and critical care medicine and
medical social sciences at the Northwestern University Feinberg School of
Medicine.
Many
hospitals and health systems are developing “decision aids,” easy-to-understand
written materials and videos to
help patients make more informed medical decisions, giving them time to develop
more realistic expectations.
After
Kaiser Permanente Washington introduced the tools relating to joint
replacement, the number of patients choosing to have hip replacement surgery
fell 26 percent, while knee replacements declined 38 percent, according to a
study in Health Affairs. (Kaiser
Permanente is not affiliated with Kaiser Health News, which is an editorially
independent program of the Kaiser Family Foundation.)
In a
paper published last year in JAMA Surgery and
the Journal of Pain and Symptom
Management, Schwarze, Kruser and colleagues suggested creating
narratives to illustrate surgical risks, rather than relying on statistics.
Instead
of telling patients that surgery carries a 20 percent risk of stroke, for
example, doctors should lay out the best, worst and most likely outcomes.
In the
best-case scenario, a patient might spend weeks in the hospital after surgery,
living the rest of her life in a nursing home. In the worst case, the same
patient dies after several weeks in intensive care. In the most likely
scenario, the patient survives just two to three months after surgery.
Schwarze
said, “If someone says they can’t tolerate the best-case scenario — which
involves them being in a nursing home — then maybe we shouldn’t be doing this.”
Maxine
Stanich was admitted to the hospital after going to the ER because she felt
short of breath. She experienced an abnormal heart rhythm in the procedure room
during a cardiac test —not an unusual event during a procedure in which a wire
is threaded into the heart. Based on that, doctors decided to implant a
pacemaker and defibrillator the next day.
Dr.
Redberg was consulted when the patient objected to the device that was now
embedded in her chest. She was “very alert. She was very clear about what she
did and did not want done. She told me she didn’t want to be shocked,” Redberg
said.
After
Redberg deactivated the defibrillator, which can be reprogrammed remotely,
Stanich was discharged, with home hospice service. With nothing more than her
medicines, she survived another two years and three months, dying at home just
after her 90th birthday in 2010.
KHN’s coverage of these topics is supported by John A. Hartford
Foundation,Gordon
and Betty Moore Foundation and The SCAN
Foundation
Liz Szabo: lszabo@kff.org, @LizSzabo
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