Advanced Cancer Patients and General Population Older Adults Differ in Preferences for a Good End-of-Life Experience

SINGAPORE—A study comparing preferences and willingness to pay for end-of-life treatments between advanced cancer patients and the general population of older adults has shown that patients are willing to pay more for all aspects of a good end-of-life experience compared with what healthy older adults believe they would pay if in a similar situation. Yet, both groups are willing to pay more to be free of pain and to die at home rather than for treatments that moderately extend life.

The research, led by members from the Lien Centre for Palliative Care (LCPC) in Singapore, was recently accepted for publication in the journal Health Policy and was presented at the LCPC-SHC Palliative Care Symposium.

Past research has shown that caregivers place a much higher emphasis on life extension and are willing to pay greater amounts for moderately life extending treatments than patients. However, it was not known whether the preferences of patients and the general population were aligned.

Led by Professor Eric Finkelstein, PhD, MHA, and Assistant Professor Chetna Malhotra, MD, MPH, from the LCPC, a centre of Duke-NUS Graduate Medical School Singapore (Duke-NUS), the study surveyed 542 adults age 50 years and older and 332 advanced cancer patients in Singapore. The former group was told to assume that they were recently diagnosed with advanced cancer, and both groups were asked to select their most-preferred end-of-life scenario from a series of options.

The scenarios were systematically varied along key features, including severity of pain experienced, amount of care required (in hours per week), expected length of survival, quality of health care experienced, expected cost of treatment, source of payment for treatment, and place of death (at home or at an institution such as a hospital). The researchers used the results to estimate the maximum amount of money participants would be willing to pay to have their preferred end-of-life scenario.

Findings showed that older adults' willingness to pay to extend their life by 1 year was valued at S$1,587 (USD$1,135), which is significantly lower than what they are willing to pay to be free of pain (S$9,358; USD$6,700), or to die at home (S$3,712; USD$2,700). Similarly, patients' willingness to pay to extend their life by one year (S$11,043; USD$7,900) was much lower than their willingness to pay to be free of pain (S$43,308; USD$30,800), or to die at home (S$19,295; USD$13,800).

Both groups also highly valued a high-quality health care experience, which includes being treated with respect and receiving care that is highly coordinated. Overall, advanced cancer patients were generally willing to pay more for all aspects of a good end-of-life experience compared to what healthy older adults stated.

Finkelstein, director of the LCPC, noted that a plausible interpretation of the results is that healthy older adults underestimate their willingness to pay for moderately life-extending treatments when they become ill with a life-limiting condition. He suspects that they may also underinsure and/or not sufficiently save for future medical needs.

Finkelstein further noted that the willingness to pay for 1 additional life year from older adults and patients is much lower than common thresholds for cost-effectiveness used in many countries. "This suggests that health reform efforts should not over-emphasize financing high-cost treatments that only moderately extend life."

Co-author Dr Chetna Malhotra advised that rather than investing heavily in high cost treatments, "Policymakers should emphasize policies that support adequate pain management and hospice home care services."

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