Singapore: An illuminating study compares the willingness of stage IV cancer
patients, and their caregivers; to pay to extend their lives by one year
against that of other end-of-life improvements. Patients with advanced cancer or other life limiting illnesses often
have to consider how much money they are willing to spend on high cost
treatments that result in only moderate improvements in length or
quality of life. These decisions are very difficult for patients to
make, and in some cases the decision is entirely deferred to a family
caregiver.
Past research has shown that in addition to extending life, being
free of pain and dying at home are important considerations for people
nearing the end of their lives. However, the value that patients place
on these considerations or their willingness to pay for either was not
previously known.
A team led by Professor Eric Finkelstein and Assistant Professor
Chetna Malhotra from the LCPC in Duke-NUS Graduate Medical School
(Duke-NUS) administered surveys to 211 patients with stage IV cancer and
their informal caregivers to find out more about their end-of-life
preferences.
Participants were asked to choose their most-preferred end-of-life
scenarios out of a series of options that varied along key dimensions,
including years of life remaining, degree of pain experienced, place of
death, level of burden on caregivers, quality of healthcare experience,
cost, and source of payment (cash, Medisave, or family members’ cash or
Medisave). Using the results, the authors quantified patients and
caregivers willingness to pay to improve their end of life experience.
They found that patients’ willingness to pay to extend their life by
one year was valued at S$18,570, which is lower than their willingness
to pay to avoid severe pain (S$22,199), or to die at home (S$31,256),
and only slightly more than their willingness to pay to receive a
high-quality health-care experience (S$16,191). Caregivers had a
three-fold greater willingness to pay than patients to extend life by
one year and for most of the other features considered.
Dr. Finkelstein believes these results suggest that health insurers
and physicians may be putting too much emphasis on life extending
treatments for these patients. He notes, “Results highlight the
importance of pain management, supporting home deaths, and addressing
other end-of-life concerns, in addition to efforts to extend life.”
Dr. Malhotra added that the differences in patients’ and caregivers’
willingness to pay suggest the need for eliciting patient preferences
directly during treatment decision making as opposed to relying on
caregiver input, “We hope this research helps foster greater
communication between patients, caregivers, and doctors”.
The team is planning to extend this research to test patient decision
aids that can help ensure that patients’ end-of-life experience is most
consistent with their preferences.
This study was supported by funding from the Lien Centre for Palliative Care (Duke-NUSLCPC(I)/2011/0001).
Full text of the study