Sociodemographic Disparities and Tumor-Specific Variation in High Intensity End-of-Life Care Among Patients with Metastatic Solid Cancer
This retrospective cohort study of nearly 34,000 metastatic cancer hospitalizations in Florida reveals that aggressive end-of-life care is prevalent (42.8%) and significantly influenced by sociodemographic disparities, tumor type, and clinical factors, with younger age, male sex, Black race, lower income, and Medicaid insurance independently associated with higher odds of receiving such interventions.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a person faces a terminal illness, the final weeks of life are often a time of profound decision-making. Families and doctors must weigh the value of extending life against the quality of that remaining time. In modern medicine, there is a growing recognition that not all medical interventions are beneficial when death is near. Some treatments, such as machines that breathe for a patient or drugs that attempt to shrink tumors, can be physically demanding and may not align with a patient's wish for a peaceful passing. Health experts have identified a pattern of "high-intensity" care—aggressive medical efforts administered in the days or weeks before death—as a potential sign that care has drifted away from a patient's true goals. Understanding who receives this intense care, and why, is crucial for ensuring that the end of life is handled with dignity and respect.
A team of researchers set out to map this landscape across the state of Florida, looking at nearly 34,000 adults with advanced, spreading solid tumors who were hospitalized in the last month of their lives. They examined hospital records from 2016 through 2023 to see how often these patients received aggressive interventions. The researchers defined high-intensity care as receiving at least one of several specific, demanding procedures: being placed on a breathing machine, receiving chest compressions to restart the heart, undergoing dialysis for kidney failure, having a tube inserted into the windpipe, or receiving cancer treatments like radiation. They wanted to know if certain groups of people were more likely to receive these treatments than others, and whether the type of cancer a person had made a difference.
The study revealed that nearly 43 percent of these patients received at least one form of high-intensity care during their final hospitalization. The most common intervention was mechanical ventilation, where a machine breathes for the patient, followed by cardiopulmonary resuscitation. The researchers found that the likelihood of receiving such care was not random; it followed a clear pattern based on who the patient was. Younger patients were significantly more likely to receive aggressive treatment than older ones. For instance, those aged 75 and older were far less likely to undergo these procedures compared to patients in their late teens or twenties. Similarly, men were slightly more likely to receive high-intensity care than women.
Race and economic status played a powerful role in these outcomes. Black patients were much more likely to receive aggressive end-of-life care than White patients, even when the researchers accounted for differences in income, insurance, and the severity of their illness. Patients living in poorer neighborhoods were also more likely to receive these intensive interventions. Conversely, patients with private insurance, those covered by Medicaid, and those living in rural areas were less likely to receive them. The type of cancer a patient had also mattered. Those with lung cancer were among the most likely to receive high-intensity care, while patients with prostate cancer were the least likely.
The study also tracked changes over time. The researchers observed a noticeable rise in the use of high-intensity care starting in 2020, a shift that persisted through 2023. This increase coincided with the global pandemic, suggesting that the unique pressures of that time—such as the risk of severe viral infection and disruptions to outpatient care—may have altered how doctors and families approached end-of-life decisions. The data showed that for most patients who received high-intensity care, it involved just one major intervention rather than a cascade of many.
These findings highlight that the intensity of care at the end of life is deeply influenced by a patient's background and the type of cancer they have, rather than just the medical facts of their disease. The authors suggest that these disparities point to a need for better communication and earlier planning, particularly for younger patients, Black communities, and those with lower incomes. By understanding these patterns, hospitals and doctors can work to ensure that the care a patient receives in their final days truly matches what they want, rather than defaulting to aggressive measures that may not serve their best interests.
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