The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine’s focus is disproportionately on curing,or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers.

The Dartmouth Atlas demonstrates that, to the extent that end of life issues are addressed in practice, they are resolved in ways that depend on where the patient happens to live, not on the patient’s preferences or the power of care to extend life. The Michigan experience of death varied remarkably from one community to another in 1995-96:

• The chance that the decedent was an inpatient in an acute care hospital at the time of death varied by a factor of two, from less than 20% to more than 40%.
• The chance of being admitted to an intensive care unit at least once during the last six months of life varied by a factor of about three, from less than 15% to more than 45%.

The intensity of care in the last six months of life also varied remarkably in 1995-96:

• The average number of visits to physicians varied by a factor of more than two, from 16 to 34.
• The number of physicians involved in patients’ care varied substantially. In some hospital referral regions almost one-third of patients saw ten or more physicians during the last six months of their lives; in other regions fewer than 9% were treated by that many different physicians.
  

Like other medical decisions, end of life decisions about the use of resources are influenced by the available supply of acute care hospital resources and by individual physicians’ practice styles. But is more better? The intensity of care in the last six months of life is an indicator of the propensity to use life saving technology. The question of whether more medical intervention is better must be framed in terms of the potential gain in life expectancy for populations living in regions with greater intensity of intervention. Research conducted in conjunction with the Atlas project provides evidence that populations living in regions with lower intensity of care in the last six months of life did not have higher mortality rates.

More than 80% of Americans say that they wish to avoid hospitalization and intensive care during the terminal phase of illness, but those wishes are often overridden by other factors. If more intense intervention does not improve life expectancy, and if most patients prefer less care when more intensive care is likely to be futile, the fundamental question is whether the quality of care in regions with fewer resources and more conservative practice styles is better than in regions where more aggressive treatment is the norm.

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NOTICE TO ATLAS READERS
While not giving answers, the atlas raises questions about health care service use that merit careful consideration. "High" rates of use are not necessarily bad and "low" volumes good (or vice versa). Our goal is to move toward rates that are consistent with high quality health care, which need to be determined with local clinical, community and patient discussion and dialogue.

The atlas is not a physician or hospital report card. When reviewing data, note that the Hospital Service Areas in the atlas were defined by the atlas author. They may differ significantly from what a hospital considers its market area.