Does profit motive explain high rates of end-of-life surgery?

Facing surgery? Ask your doctor about any precautions you should take before going under the knife. Will an antibiotic be given before surgery? Avoid shaving near the incision site (often recommended in order to minimize the risk of infection). Studies have shown that surgical errors are less common when surgical teams run down a checklist to verify all critical information (patient identity, surgery to be performed, which side to do the surgery, etc.). Ask that the checklist be discussed while you are still awake and capable of listening and make sure your surgeon is present during the checklist discussions. istockphoto

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(CBS) Have surgeons gone scalpel-happy? New research shows that many elderly patients get surgery at the end of life - and some are saying the operations are being performed not because the patients want or need them, but because the surgeons and hospitals are financially motivated to do surgery.

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For the study - published in the Oct. 5 issue of The Lancet - researchers analyzed data from nearly 2 million Medicare patients, aged 65 and older, all of whom who died in 2008. The researchers found nearly one in five of them underwent surgery in their last month of life, with one out of 10 undergoing a procedure in the week before they died. The study suggest many of these patients were already going to die

The authors of the report say regional factors may be at play, because larger hospitals have 40 percent more beds, and the study found those hospitals had more end-of-life surgeries and significantly higher Medicare spending. That suggests, according to the authors, that these surgeries are influenced by the hospital's culture, rather than what is medically appropriate or what the patient prefers.

"In a lot of places, we're doing a lot of these surgeries I think unnecessarily," study author Dr. Ashish Jha, professor of health policy from Harvard School of Public Health, told Bloomberg. "We're not having the kinds of conversations with patients that we need to have, about what they want out of their last few days and how we help them achieve those goals."

In an editorial that accompanied the study, Dr. Amy Kelley, an assistant professor of geriatrics at Mount Sinai School of Medicine in New York City, said that money is a motivator, because Medicare is guaranteed to pay for these procedures, regardless of whether the patient wants it or not.

"Policymakers must align incentives for insurance plans, health-care institutions, and providers with individual patient goals," Kelley said in an emailed written statement.

But do surgeons really slice people open because they want to line their pockets?

"I do not know a single surgeon who says, 'We're going to do this because there's a financial incentive,'" Dr. Frank Opelka, an associate medical director at the American College of Surgeons, told HealthDay. "These patients are absolutely facing the most difficult time in their life, and the profession just doesn't act that way."

Jha agreed that some procedures were likely necessary to relieve pain or suffering, but told the New York Times the story of one patient to illustrate his point. A man at his hospital was dying of pancreatic cancer, but doctors performed several tests and surgery to stop an unrelated internal bleeding problem. Jha said his hospital's team was just "desperate" to find something they could fix.

"The tragedy is what we should have done for him but didn't," Dr. Jha told the Times. "We should have given him time to have the conversation he wanted to have with his family."

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