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One way America handles end-of-life care better than Canada


Dying in America is an expensive and intensive process. Many patients die in the hospital, often receiving painful treatments, when what they'd really prefer is a comfortable death at home among family members. About a quarter of Medicare's annual budget is spent on patients in their last year of life.

End-of-life care in the United States doesn't always work in the best interests of the patient — but it turns out that's not a uniquely American problem at all.

A consortium of 17 international researchers published research Tuesday comparing end-of-life care for cancer patients in seven developed nations. It shows that the United States, in some ways, offers less intensive care than other countries. American cancer patients, for example, are less likely to die in hospitals than Canadians or Brits. The average Belgian will spend about 10 days of the last month of life at a hospital. In the United States, that number hovers around five days.

"We know that patients want to die at home; we constantly hear this," says Zeke Emanuel, a bioethicist at University of Pennsylvania and co-author of the study. "When you look at that metric, in these seven countries, we're actually doing the best."

There are still some ways the United States stands out — American patients, for example, are much more likely to get certain intensive treatments, like chemotherapy or ICU visits, as they near death.

But overall, the new paper suggests that despite huge structural differences between the US and foreign health care systems, the way the United States handles end-of-life care is less remarkable than many have assumed.

Americans are less likely to die in the hospital than Canadians, Belgians, or Brits

Survey after survey shows that most patients want to die at home, rather than in the hospital. The United States, it turns out, is doing relatively well at respecting that wish.

An estimated 22.2 percent of American cancer patients die in the hospital (or skilled nursing facilities, another health care–intensive environment included in this tally). That's half the rate of hospital deaths in England, and 40 percent of the rate in Canada and Belgium.

This suggests that on this particular metric, the United States is doing better than peer countries at helping patients die in the settings they prefer.

It's possible that America's high health care costs play a role here. Hospital stays are much more expensive in the United States than they are in other countries, so there's a greater financial incentive to avoid admissions. Those economic pressures coupled with patient preferences might have the effect of pushing care into different settings than would be seen in other countries.

Americans still get more intensive care at the end of life

It's true that Americans are less likely to die in the hospital than residents of other countries — but it's also the case that those who do end up in the hospital face more intensive care than patients internationally.

Take the case of intensive care unit admissions. In the last six months of life, 40.3 percent of American cancer patients will have one. In Germany, the number hovers just above 8 percent; in Canada, it's 15.2 percent.

Or you can look at another intensive treatment, chemotherapy. In the United States, 10.6 percent of cancer patients receive chemotherapy treatments in their last month of life. The numbers are lower elsewhere: 8.8 percent in Canada and 4.8 percent in Norway.

This means more American cancer patients are spending their last days of life undergoing an intensive, sometimes painful, and ultimately unsuccessful treatment — days they could have spent mediating symptoms and spending time with the people they cared about the most.

"The suggestion from this data is that once you get into the clutches of the hospital system, you're going to get some very intensive treatment," says Emanuel.

The United States isn't an outlier with end-of-life care spending

The United States is typically the most expensive at anything when it comes to health care. The price of getting something as standard as a CT scan is nine times as much here as it is in Canada.

Whenever you look at any chart of international health care spending, the United States is routinely an outlier — a dot all the way at the top of the chart while other countries huddle much lower on the axes.

That's what makes this chart from the JAMA paper so remarkable: It shows that when you focus just on end-of-life care, the United States isn't an outlier at all. We're, astonishingly, with the rest of the pack on hospital spending in the last six months of life.

(Journal of the American Medical Association)

This doesn't suggest that Americans have figured out the right way to die. There are numerous problems with end-of-life care in the United States, which you can read more about here.

Instead, it suggests that the United States is no more wrong than other peer countries — that, unlike some issues that plague the American health care system specifically (high prices, for example), this is an issue that all countries are currently struggling to get right.

"There's this idea that if you look at European countries, their attitude toward death is so much more normal, they must be doing this right; just look at our high health care costs at the end of life," Emanuel says. "But if you look at the data, you start to see that's just not the case."

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