A study published Online First in The Lancet has revealed that nearly a third of elderly American beneficiaries of fee-for-service Medicare receive surgery during their last year of life, most procedures are performed in the month before death, however, the probability of receiving surgery at the end of life varies significantly according to the patient’s age, their area of residence and availability of hospital beds. This suggests that some operations could be either avoided or were discretionary, but it could also indicate a financial motivation as surgical procedures are highly paid, and therefore the surgery may not comply with the wishes of dying patients.

It is a well established fact that patients at the end of their lives receive aggressive medical care; a fifth of elderly Americans die in intensive care, approximately half are mechanically ventilated and a quarter receive pulmonary resuscitation within days prior to their death. At present, researchers know little about surgical care during this period.

In their study, Ashish Jha from the Harvard School of Public Health in Boston, USA, and his fellow researchers examined data from over 1,802,000 beneficiaries of fee-for-service Medicare in the USA who were 65 years or older and died in 2008. They examined the frequency of elderly Americans who underwent surgery in the last year of life and whether important regional factors, such as the number of hospital beds and availability of surgeons had an impact on the provision of surgical interventions to dying patients.

The researchers discovered that almost one in five beneficiaries of fee-for-service Medicare who died in 2008 had surgery during the last month of their life, with almost one in ten patients undergoing a surgical procedure within their last week of life.

The findings also revealed that the number of patients undergoing end-of-life surgery was highest amongst younger patients, i.e. 38.4% of people were 65 years old, 35.3% were 80 years and 23.6% aged between 80 and 90 years.

The study showed that the highest intensity region of Munster in Illinois had a three time greater rate of surgical procedures compared with the lowest intensity region of Honolulu.

The authors note that the findings suggest that the availability of hospital heads per head, irrespective of the number of surgeons, potentially increases patients’ chances of receiving surgery at the end of life. High-intensity regions have almost 40% more beds per head compared with low-intensity areas and also have substantially higher Medicare spending.

The authors voice their concern regarding the likelihood of elderly Americans receiving surgery at the end of life potentially being influenced by factors, such as health-care provider practices and culture instead of appropriate medical care or individual patients’ preferences:

“For clinicians, these data should prompt careful consideration of a patient’s goals when assessing the need for surgical intervention at the end of life.”

Leading author Ashish Jha concludes saying:

“Future research needs to focus on why these large variations exist. For policy makers seeking to reduce variation in care, focus could be directed to factors that lead to excess supply such as payment systems that reward quantity of care over the quality and appropriateness of care.”

Amy Kelley from the Mount Sinai School of Medicine in New York, USA, states in a comment:

“The provision of appropriate, preference-guided treatment for patients with serious illness is the shared responsibility of all clinicians. Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals…Policymakers must align incentives for insurance plans, health-care institutions, and providers with individual patient goals.”

Written by Petra Rattue