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Health Care Decisionmaking

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More than one in three seriously ill people who prefer comfort care over aggressive treatment don't get it

According to a recent study, more than one in three seriously ill people who preferred comfort care received aggressive treatment instead. This discord was associated with higher 1-year health care costs, but it increased survival.

Physician-patient communication apparently needs to be improved to ensure that patients receive the care they want. Adapting medical care to patients' treatment goals might substantially lower costs, although at some reduction in survival, concludes Joan M. Teno, M.D., M.S., of Brown University. The study was supported in part by the Agency for Healthcare Research and Quality (HS08158).

Dr. Teno and her colleagues interviewed 1,185 seriously ill Medicare patients (or their surrogates) at five U.S. teaching hospitals about whether the care they received was consistent with their preferences. Of patients who wanted aggressive life-extending treatment, 86 percent said they obtained it, but only 41 percent of those preferring comfort care obtained it. In fact, more than one-third (35 percent) of those who preferred comfort care said that the medical care they received was inconsistent with their goals. This group had higher estimated mean 1-year health care costs than those who received care consistent with their wishes ($92,442 vs. $52,098).

Even after adjustment for differences in disease severity, age, sex, race, functional status, income, and years of education, adjusted costs were 1.4 times higher for patients who wanted comfort care but received aggressive care instead. However, 1-year survival was lower in patients who wanted comfort care and received it than those who wanted it and received aggressive care instead. Regardless of patients' preferences, those who received life-extending care had more than a 50 percent 1-year survival rate compared with a 38 percent survival rate for those who received comfort care.

See "Medical care inconsistent with patients' treatment goals: Association with 1-year Medicare resource use and survival," by Dr. Teno, Elliott S. Fisher, M.P.H., Mary Beth Hamel, M.D., and others, in the March 2002 Journal of the American Geriatrics Society 50, pp. 496-500.

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