End-of-life care in U.S. not as costly as in Canada, Penn study finds

The United States has a reputation for providing costly — and often unwanted — end-of-life care. But the first study to do an international comparison finds it’s not as egregious as we thought.

Compared with patients in other developed nations, Americans diagnosed with cancer spend more time in the intensive care unit and get more chemotherapy in the last months of their lives.

But fewer patients are in the hospital when they die. And the overall bill, while high, isn’t the steepest. That honor goes to Canada.

“We found that end-of-life care in the United States is not the worst in the world, and I think that surprises a lot of people,” said Dr. Ezekiel Emanuel, a medical ethicist at the University of Pennsylvania.

Researchers compared the expenses, the location of death, and the types of treatments cancer patients received in the U.S., Canada, and five European countries.

The average cost for the last six months of life was highest in Canada, at $21,840 per patient, followed by Norway, with $19,783, and the United States, with $18,500. England spent the least, or just $9,342 per patient.

Americans were about twice as likely to be treated aggressively in the ICU, but also half as likely to be in a hospital at all.

“We still seem to be a little schizophrenic about things,” said Emanuel, noting that in many cases doctors try new treatments up until the last few weeks or days, and only then consider hospice or at-home care. “We need to move that thinking closer to the time when it’s quite clear they’re terminally ill.”

The results were published on Tuesday in JAMA.

Partly due to the high price of hospital care, Emanuel said, the U.S. has made an effort to create alternatives such as hospice.

“We’ve had 30 years since passage of the hospice benefit for Medicare in which to develop these interventions, and we’ve done a very good job,” he said. “And it’s not as well developed in other countries.”

Penn physician and first author Justin Bekelman added that the results debunk the common wisdom that excessive spending near death is driving the nation’s inordinately high health care bill.

“What our study shows is that end-of-life care is not the main contributor to higher health care costs in the United States,” he said. “Some countries with considerably lower overall health care costs still spend more on end-of-life care.”

The priority, he emphasized, should always be to provide better care, not necessarily cheaper care. But as America moves away from the traditional fee-for-service model, superior care at a lower cost is likely to follow.