Many Medicare Patients Get Surgeries in Last Year of Life: Study

Wide variations seen in number of procedures, depending on region where patient lives

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THURSDAY, Oct. 6 (HealthDay News) -- As many as one-third of Medicare beneficiaries in fee-for-service plans have inpatient surgery in the last year of their life, a new Harvard study finds.

But the issue of whether such surgery is necessary or not is a tricky one that can only be decided by the doctor, the patient and patient's family, said Dr. Frank Opelka, an associate medical director at the American College of Surgeons.

Nor is there any good way to predict when an elderly patient is going to die.

"There's no way possible to know ... if it's the person's last year of life," said Jane Bolin, an associate professor of health policy and management at Texas A&M Health Science Center School of Rural Public Health in College Station. "The doctor doesn't know. The patient doesn't know."

Dr. Alvin Kwok and colleagues published their findings in the Oct. 6 online edition of The Lancet.

It's been well-noted that treatment intensity tends to step up at the end of a person's life, often involving intensive-care stays, ventilators and pulmonary resuscitation in the days before someone dies.

Less is known about surgery at this vulnerable period of life.

By analyzing Medicare claims data the study authors found that, in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.

As participants progressed in age, the proportion of people undergoing surgery declined: 38.4 percent among 65-year-olds, 35.3 percent at age 80 and 23.6 percent for those between 80 and 90.

The most surgeries were performed in Munster, Ind., and the fewest were done in Honolulu; surgeries tended to be more common in hospitals with more beds available.

An accompanying commentary from Dr. Amy S. Kelley of Mount Sinai School of Medicine in New York City pointed out that Medicare reimbursement rates for surgery are highly lucrative, suggesting that "surgeons and hospitals are often financially motivated to operate, regardless of the patient's preferences or goals."
But other experts disagreed that this might be the case.

"I do not know a single surgeon who says, 'We're going to do this because there's a financial incentive,'" Opelka said. "These patients are absolutely facing the most difficult time in their life, and the profession just doesn't act that way."

Instead, the issue might be one of how the medical community and the larger community might start discussing the inevitability of death.

"We want to do everything we can when we have the opportunity but when we reach a point of futility, we have to have a mature conversation," Opelka said. "It's no longer about getting past an acute, life-threatening situation but the inappropriate prolonging of the dying process, giving the patient dignity and control of a God-given process," he noted.

"We've grown up believing we can get anything and buy anything," Opelka added. "We can't buy eternity."

SOURCES: Frank Opelka, M.D., associate medical director, American College of Surgeons, Washington, D.C., and professor, surgery, and vice chancellor, clinical affairs, Louisiana State University, New Orleans; Jane Bolin, Ph.D., J.D., associate professor, health policy and management, Texas A&M Health Science Center School of Rural Public Health, College Station, Texas; Oct. 6, 2011, The Lancet, online

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