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One of the most pervasive ideas about death in America is that we don't do it well, dying in hospital beds after enduring unnecessary medical procedures instead of at home. It's our uncomfortable relationship with death, the thinking goes, that's pushing the relentless rise of our health-care spending to the highest in the world.

A new study of cancer patients over age 65 complicates that notion, finding that while pieces of the story are right, much of it is not. Among the seven countries studied, American cancer patients were the least likely to die in a hospital bed. They spent the fewest days in the hospital during the final six months of life. Hospital spending during that period was high, but trailed Canada and Norway.


"When I tell people the results -- we have the lowest deaths in the hospital and we're not the most expensive -- there isn’t a single person who isn’t surprised and shocked," said Ezekiel J. Emanuel, the leader of the study and an architect of the Affordable Care Act who now heads the medical ethics and health policy department at the University of Pennsylvania Perelman School of Medicine. "We’ve spent two years going over this data meticulously precisely because we were shocked."


The notion that Americans die in an expensive, intrusive way that is contrary to most patients' wishes is entrenched, Emanuel said. After he left the White House and gave public talks about health care, end-of-life care constantly came up as a major factor in spiraling health-care costs.

The idea follows from two powerful data points. Roughly a quarter of the Medicare budget is spent on health care during people's last year of life. At the same time, the U.S. spends much more per person on health care than any other developed nation. To many people, those facts seem likely to explain one another, fertilized by the power of anecdote; everyone knows a story about someone who passed away after a needless last-minute surgery or suffered the side effects of drugs that never had a chance of curing them.


But Emanuel realized that despite doing end-of-life research for three decades, he didn't actually know how end-of-life care contributed to health-care spending in the U.S. compared with other countries. As he began to study the question, some things held true -- Americans are far more likely to get high-tech interventions. But the overall narrative began to fray.

Although the proportion of Medicare spending on people's last year of life is high, it hasn't really budged for a couple decades. Emanuel has found that, when looking at people of all ages who die, the final year accounts for a much smaller fraction of total health spending -- about 10 to 12 percent.

The new study, published Tuesday in the Journal of the American Medical Association, does reinforce concerns about how people die in the U.S. compared with other countries. American cancer patients experience more aggressive interventions near the very end than in other wealthy countries studied. Even though older American cancer patients were less likely to be hospitalized in their final six months than every country but Germany, they were twice as likely to be admitted to the intensive care unit than any other countries. And 39 percent of them received chemotherapy -- more than patients in Belgium, Canada, Germany, Norway and the Netherlands.

To Emanuel, the data hold mixed messages: first, hope. The way Americans die of cancer is evolving. In the 1980s, 70 percent of cancer patients died in the hospital. At least among older cancer patients, the new data suggest only a fifth die in hospital beds today. But at the same time, the study suggests there should be greater scrutiny of the medical care people receive at the end of life.

"Clearly, I think, these data suggest the focus now has to be on stopping using high technology that patients don't want. Almost no patient says, 'I want to die in the ICU,' and yet we're admitting over 40 percent of patients to the ICU" in their last six months, Emanuel said. "This isn't about death panels, this is about not doing things patients don't want. Patients don't want these high-tech things in the last month of life."


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