Preferences for a good end-of-life experience

October 7, 2015

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 to 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), was recently accepted for publication in the journal Health Policy and will be presented on Oct. 8, 2015 at the LCPC-SHC Palliative Care Symposium.

Faced with an ageing population and rising rates of chronic diseases, Singapore has been forced to revisit how best to finance health services for the Pioneer Generation and is interested to understand the perspective of those most at risk, which includes older adults and patients with life-limiting illnesses, such as advanced cancer.

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 and Assistant Professor Chetna Malhotra from the LCPC, a centre of Duke-NUS Graduate Medical School Singapore (Duke-NUS), the study surveyed 542 adults aged 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 over 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 healthcare experienced, expected cost of treatment, source of payment for treatment and place of death (at home or 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 one year was valued at S$1,587, which is significantly lower than what they are willing to pay to be free of pain (S$9,358), or to die at home (S$3,712). Similarly, patients’ willingness to pay to extend their life by one year (S$11,043) was much lower than their willingness to pay to be free of pain (S$43,308), or to die at home (S$19,295). Both groups also highly valued a high quality healthcare 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.

Dr 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. “If confirmed, then mandates to purchase health coverage, as is the case with Medishield Life, could make people better off by minimising the chances of regret from past decisions.”

Dr Finkelstein further notes that the willingness to pay for one 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-emphasise financing high cost treatments that only moderately extend life.”

Co-author Dr Chetna Malhotra advises 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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