• Do poorer people want more extreme measures at the end-of-life?

    A reader writes in to the blog:

    My brother, an ICU physician, has observed anecdotally an apparent correlation between family wealth and propensity for insisting on no-holds-barred, last-ditch interventions to extend life.  In his experience, the poorer the family, the more likely they are to want extreme measures.

    Has this ever been studied systematically?  If its true, it could have some implications for how we view medical decision-making.

    I hear this kind of thing all the time. It’s always seemed apocraphyl to me, but I could be wrong. And, it’s an answerable question. So I went to the literature. Here’s what I found.

    1) Racial variation in end-of-life intensive care use: a race or hospital effect? Conclusions: The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital. My comment: The use of ICUs at the end of life was more due to between-hospital differences than within-hospital differences. In other words, some hospitals were more likely to send patients to the ICU, and those hospitals were more likely to see minority patients. It wasn’t caused by the patients themselves.

    2) Racial and ethnic differences in preferences for end-of-life treatment. Conclusions: Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV [mechanical ventilation]. My comment: Even though there were some racial differences in preference of life-sustaining treatment, the majority of patients of all races and ethnicities preferred not to have them.

    3) The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Conclusions: We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. My comment: While some racial differences existed, there were no differences by socio-economic status.

    4) Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites? Conclusions: At life’s end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest. My comment: Even after controlling for other factors, it appeared that minority patients received significantly more end-of-life care. The authors stress, however, that it’s unclear how much of that treatment was actually sought.

    5) Determinants of medical expenditures in the last 6 months of life. Conclusions: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics. My comment: About 10% of variance in end-of-life expenditures can be explained by patient characteristics.

    So what’s the answer? Here’s the best I can do: There do seem to be some patient level differences in end-of-life care by race and ethnicity. Blacks and Hispanics appear to get more care and have higher expenditures. But, and this is a big but, there are caveats. Some of this difference may be due to hospital differences. They may also be due to the fact that those groups may have less care before the end-of-life, they may be less likely to have advance directives, and they may have been presented options in different ways. Moreover, the one study that looked at socio-economic status did not find that wealth had anything to do with these differences.

    So, getting back to the reader’s original question, it doesn’t appear that poorer patients are more likely to want extreme measures. In fact, there’s evidence that being poor or wealthy is not a predictor of end-of-life expenditures or interventions.

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    • I generally agree with your conclusions, however one aspect over looked is the health literacy of the patient and or family. Are the minority or lower socioeconomic patients and their families more likely to follow what the doctor recommends and/or are less likely to make a decision to withdraw support or limit treatment due to a lack of knowledge even if the physicians does suggest limiting care.

      • Excellent point, and I should have made that clearer. I was trying to get at that when I was talking about how patients are presented options.

    • Sinister thought…

      Inheritance may be?