How much end‐of‐life care is of low value?

A significant proportion of healthcare expenditure is spent on patients in their last year of life. In the United States, such patients accounted for 25% of the Medicare budget in 2009,1 with more recent data from 2009 to 2011 from nine developed countries showing the share of total healthcare spend incurred ranging from 8.5% in the United States to 11.2% in Taiwan.2 In Australia, hospital care for the last year of life for those aged 65 years and over constitutes around 9% of all inpatient costs.3

A rising concern is how much of this relatively expensive end‐of‐life care is of low value, that is, ineffective or even harmful. In one study, 12% of admissions to three Australian tertiary hospitals involving patients at the end of life involved the administration of futile care, as defined by audit criteria and expert consensus.4 A systematic review of 38 studies found that on average one in three older patients in the last 6 months of life received interventions in hospital that were very unlikely to confer benefit.5 These included dialysis, radiotherapy, transfusions, antibiotics, life support treatments and unnecessary and often invasive investigations. The same review found non‐beneficial intensive care unit admission involved one in 10 patients. Surveys of older patients in the United States indicate receiving inappropriate care with its unintended consequences is perceived as more of a problem than being denied appropriate care.6

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