Patients, caregivers differ on end-of-life choices

When asked how much they were willing to pay to improve end-of-life experiences, caregivers had a three-fold greater willingness to pay than stage IV cancer patients to extend life by one year. (Credit: iStockphoto)

People with stage IV cancer are less willing to pay for another year of life than they are to die at home or avoid severe pain—and are only slightly more willing to pay more to receive a high-quality health-care experience.

The findings suggest that there may be too much emphasis on life-extending treatments, researchers say.

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.

Who decides?

These decisions can be 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 has not been known.

For a new study, published in the journal Palliative Medicine, researchers surveyed 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, 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).

Ask the patient

Researchers then 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 $13,681, which is lower than their willingness to pay to avoid severe pain ($16,355), or to die at home ($23,027), and only slightly more than their willingness to pay to receive a high-quality health-care experience ($11,928). (Figures converted from Singpore to US dollars.)

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.

The results suggest that health insurers and physicians may be putting too much emphasis on life extending treatments for these patients, says Eric Finkelstein, a professor in the Lien Centre for Palliative Care at the Duke-National University of Singapore Graduate Medical School.


“Results highlight the importance of pain management, supporting home deaths, and addressing other end-of-life concerns, in addition to efforts to extend life.”

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, says Chetna Malhotra, assistant professor at Duke-NUS.

“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.

The Lien Centre for Palliative Care funded the research.

Source: Duke-National University of Singapore