"He said, 'Those buggers were poking and prodding her with needles the day before she died," recalled Prof. Fassbender, a health economist at the University of Alberta. "He was very bitter about that."
A growing body of thought suggests such assertive treatment is, in fact, often inappropriate for patients facing imminent death from cancer or other terminal diseases. A new Ontario study reveals, however, that cancer patients are increasingly undergoing emergency-department treatment, chemotherapy and other "aggressive" care in the last few weeks of their lives.
Close to one in four patients studied received potentially aggressive care in their last month, it found. Care of all kinds in the last months of life generally costs the health-care system billions of dollars a year, other research has suggested.
The oncologist who led the Ontario study, Dr. Craig Earle of Toronto's Sunnybrook Health Sciences Centre, said hospice beds and palliative services in patients' homes are often not available. He and other experts advocate new government spending on palliative care, designed to lessen pain and discomfort and address psychological and spiritual issues for patients whose illness can no longer be treated.
Resources are not the only issue, though. Experts say attitudes within medicine and in society as a whole still tend to swing toward heroic attempts to extend life, rather than easing certain patients more peacefully toward an inevitable death.
"It's human nature. We root for the underdog. We like to gamble. We buy lottery tickets even though the probability of winning is small," said Prof. Fassbender, whose research focuses on end-of-life care and its costs. "Similiarly, when cancer patients are confronted with treatment, even if the probability of success is low, they still may opt for it, because that correlates with hope ... But it may be false hope."
Dr. Larry Librach, a palliative-care physician at Toronto's Mount Sinai Hospital, said the culture is embodied by an old joke among physicians: "Why do they put nails in coffins? ... To prevent the oncologists giving them any more chemo."
Younger cancer doctors are becoming increasingly attuned to palliative care and cancer centres are beginning to include such treatment among their services, he said, but the old mentality persists in some corners.
"I know a couple of oncologists who have never accepted the idea of palliative care," said Dr. Librach, a spokesman for the Canadian Hospice and Palliative Care Association. "They're never-say-die oncologists. There's always something more [they can do]."
Caring for someone at the end of their life consumes a huge portion of the medical system's efforts and budget. A 2004 Manitoba study suggested 21% of health-care spending - which would amount to about $28 billion nationally - is spent on treating people in their final six months.
The study by Dr. Earle and colleagues, just published in the Journal of Clinical Oncology, analysed data on 227,000 Ontarians who died from cancer between 1993 and 2004. The researchers looked at whether they received potentially aggressive care, defined as chemotherapy within 15 days of death and more than one emergency-department visit, at least one ICU admission or one hospitalization within 30 days of the end.
They found close to one in four had received such treatment, and the numbers had crept up by an average of 1% in each of the 10 years. That has not reached U.S. levels, and some of the treatment may have been reasonable in the circumstances, without the hindsight of knowing when the patient would die, said Dr. Earle, who worked 10 years in the States.
Still, he said it underlines the need for expanded hospice services, an area where the American system actually performs better.
People have the right to decide on their treatment, but physicians often do not give them the whole story, said Dr. Librach, a spokesman for the Canadian Hospice Palliative Care Association. That means letting patients know exactly how long a particular drug or round of chemotherapy will extend their lives, what side effects that treatment will bring and the alternative benefits of palliative care, he said.
While medical advances have turned many cancers into chronic, survivable diseases, half of the people diagnosed with cancer still die from it.
"One thing I often say to patients is 'If you get another month of life, what are you going to do with it? Other than feel sick from chemo.' "
Prof. Fassbender offered a wish list of measures to enhance end-of-life treatment: better education of medical students about palliative care; boosting fees for family doctors to encourage them to visit dying patients at home; funding hospice beds and providing more palliative care in hospitals.
One-time funding set aside in the Conservative government's recent budget for palliative care was a promising sign, though it amounted to just $10 per dying patient, he said.