Failures in end-of-life care, rampant overtreatment and potential cures, and climate change links to health

July 16, 2015

In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.

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A study in JAMA Oncology published last week, and featured on NPR, finds that young adults with terminal cancer suffer through intensive treatments in their last days, with 22 percent receiving care in the ICU and 22 percent having at least one ED visit in their final month. The standard of care for terminal adult cancer patients is less than 4 percent receiving intensive treatment. Jennifer Mack, MD, at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, the lead author of the study, believes some (if not many) young patients might have benefitted more from hospice at home surrounded by loved ones. The mismatch between what oncology advocates as standard of care and what happens in actual practice is highlighted further by the fact that 90 percent of doctors would themselves forgo aggressive treatment if faced with a terminal illness according to one Stanford University study. While it’s unclear whether the young patients wanted intensive care, better communication and understanding about end-of-life options for both young and old patients is often lacking. A study from Johns Hopkins found that 40 percent of participants had not discussed their preferences at all prior to their death.


Robert Pearl, MD, CEO of The Permanente Medical Group, in Forbes this week wrote about the epidemic of overtreatment. He offers examples of instances in which tests and procedures are performed with limited evidence of benefit: 22.5 percent of pacemakers are inserted unnecessarily, tens of thousands of Americans undergo surgery for back pain that yields no relief, and as much as 29 percent of cancer patients suffer rounds of chemotherapy in the last two weeks of their lives, contrary to standard of care. Pearl blames cultural biases and perverse financial incentives for overtreatment, suggesting that such entrenched causes will make this problem difficult to solve. To address unnecessary care, he suggests four steps: empower patient decision-making, shift to value-based pay practices, determine when new approaches are really better, and reform medical malpractice. A Wall Street Journal piece points out that unnecessary double mastectomy is on the rise, fueled at least in part by the “Angelina effect.” (Angelina Jolie has the breast cancer mutation BRCA1 and has been public about her decision to undergo prophylactic mastectomy.)


The link between climate change and health is complex and unclear; some compare the current state of evidence to the early days of research on the link between smoking and lung cancer. However, as The New York Times reports, evidence is growing. The National Climate Assessment released this spring included 400 pages on the impact of climate change on health. The report highlights topics that range from temperature-related death and illness to mental health and wellbeing, and concludes: “Climate change is a significant threat to the health of the American people… As the climate continues to change, the risks to human health continue to grow.” Important to note is the protective effect of material wealth; in wealthier countries like the U.S., access to luxuries like windows that shut and air conditioning can help minimize the impact of climate change on health. Developed countries are not immune to the risk of worsening asthma, heat-related deaths, or vector-borne disease. In a recent conversation with a gathering of physicians and medical students, Bernard Lown, MD pled for “systemic change” in U.S. policy. He said, “That change must include medicine, education, social inequality, and global warming. Physicians cannot be aloof about these issues. And poverty is the first thing we must address.”




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