Article:
Alexi A Wright , assistant professor of medicine 1, Baohui Zhang , research statistician 2, Nancy L Keating , associate professor of medicine and health care policy 3, Jane C Weeks , professor of medicine 1, Holly G Prigerson , professor of medicine 2 1Harvard Medical School, Department of Medical Oncology, Dana-Farber Cancer Institute, Dana 1133, 450 Brookline Avenue, Boston, MA 02215, USA 2Center for End-of-Life Research, Weill Cornell Medical College, New York, NY 10065, USA 3Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115, USA Correspondence to: H G Prigerson hgp2001{at}med.cornell.edu Accepted 27 January 2014

 Abstract Objectives To determine whether the receipt of chemotherapy among terminally ill cancer patients months before death was associated with patients’ subsequent intensive medical care and place of death. Design Secondary analysis of a prospective, multi-institution, longitudinal study of patients with advanced cancer. Setting Eight outpatient oncology clinics in the United States. Participants 386 adult patients with metastatic cancers refractory to at least one chemotherapy regimen, whom physicians identified as terminally ill at study enrollment and who subsequently died. Main outcome measures Primary outcomes: intensive medical care (cardiopulmonary resuscitation, mechanical ventilation, or both) in the last week of life and patients’ place of death (for example, intensive care unit). Secondary outcomes: survival, late hospice referrals (≤1 week before death), and dying in preferred place of death. Results 216 (56%) of 386 terminally ill cancer patients were receiving palliative chemotherapy at study enrollment, a median of 4.0 months before death. After propensity score weighted adjustment, use of chemotherapy at enrollment was associated with higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) and late hospice referrals (54% v 37%; 13.6%, 3.6% to 23.6%) but no difference in survival (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). Patients receiving palliative chemotherapy were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; −10.8%, −1.0% to −20.6%), compared with those who were not. Patients receiving palliative chemotherapy were also less likely to die in their preferred place, compared with those who were not (65% v 80%; adjusted risk difference −9.4%, −0.8% to −18.1%). Conclusions The use of chemotherapy in terminally ill cancer patients in the last months of life was associated with an increased risk of undergoing cardiopulmonary resuscitation, mechanical ventilation or both and of dying in an intensive care unit. Future research should determine the mechanisms by which palliative chemotherapy affects end of life outcomes and patients’ attainment of their goals.

 Introduction Chemotherapy is used to treat metastatic cancer, with the goal of palliating symptoms and improving survival. Between 20% and 50% of patients with incurable cancers receive chemotherapy within 30 days of death,1 2 despite growing concerns that it may not be effective. Recently, the American Society for Clinical Oncology identified end of life chemotherapy as one of the “top five” practices that could improve patients’ care and reduce costs, if stopped.3 Deciding when to discontinue chemotherapy is often challenging, however, given limited data on whether chemotherapy is helpful or harmful in the final months of life.2 4 5 Research suggests that the use of chemotherapy within two weeks of death is associated with lower rates of hospice use,6 7 but only 6.2% of patients receive chemotherapy this late.8 Most decisions about treatment occur months before death, when data to guide decision making about chemotherapy are more limited. For example, in a randomized controlled study comparing early palliative care integrated with oncology care versus standard oncology care among patients newly diagnosed as having metastatic lung cancer, Greer et al found that 62% of all enrolled patients received chemotherapy within two months of death.9 10 However, patients who received concurrent palliative and oncologic care stopped intravenous chemotherapy an average of two months earlier than did those in the standard oncology group but had a longer median overall survival and were more likely to receive at least one week of hospice services.9 10 To our knowledge, however, Greer at al’s study and others have not specifically examined whether the use of chemotherapy in the months leading up to the patient’s death is associated with the subsequent receipt of intensive medical care in the last week of life or death in an intensive care unit. In this secondary analysis of Coping with Cancer data,11 we sought to determine whether terminally ill cancer patients who were receiving chemotherapy at study enrollment were more likely to receive intensive medical care in the last week of life and die in an intensive care unit, compared with those who were not. We hypothesized that palliative chemotherapy would be associated with more intensive medical care (for example, cardiopulmonary resuscitation, mechanical ventilation, or both) and late referrals to a hospice, as chemotherapy is often an exclusion criterion for hospice admission,12 13 and oncologists express reluctance about discussing advance care planning while prescribing chemotherapy.14 15 16 Similarly, we expected that patients receiving palliative chemotherapy would be less likely to die where they wanted to, as oncologists often delay discussing patients’ preferred site of death, compared with other non-cancer specialists.14

 Methods Coping with Cancer was a federally funded, prospective, longitudinal, multi-institution cohort study of terminally ill cancer patients and their informal caregivers, which was designed to examine how psychosocial factors influence patients’ medical care and caregivers’ adjustment to bereavement.11 Of 917 eligible patients, 638 (69.6%) consented and enrolled in Coping with Cancer. The three most common reasons for non-participation were “not interested” (n=120), “other” (n=69), and “caregiver refuses” (n=37). Participants were more likely than non-participants to be Hispanic (12% (75/638) v 6% (16/279), P=0.006), but otherwise did not differ by sociodemographic characteristics. This report describes 386 patients who were recruited between October 2002 and February 2008 and died during the course of the study, such that we could analyze their end of life medical care. We excluded participants in clinical trials (n=37), as their treatment preferences and therapeutic expectations often differ from those of patients receiving standard chemotherapy or supportive care.17 Patients who had died as of February 28, 2008 did not differ significantly in type of cancer or receipt of chemotherapy from participants who lived. However, decedents had worse performance status, more symptoms, and greater awareness of terminal illness and were more likely to be male, unmarried, uninsured, less educated, younger, and non-white (all P<0.05). Participating sites included Yale Cancer Center, the Veterans Affairs Connecticut Healthcare System Comprehensive Cancer Clinics, the Parkland Hospital Palliative Care Service, Simmons Comprehensive Cancer Center, Massachusetts General Hospital, Dana-Farber Cancer Institute, Memorial Sloan Kettering Cancer Center, and New Hampshire Oncology-Hematology. The Dana-Farber/Harvard Cancer Center’s Office for Human Research Studies coordinated the study, and all patients provided written informed consent. Patients were eligible to participate if they had metastatic cancer that had progressed through at least one chemotherapy regimen, had a physician formulated prognosis of six months or less to live, were aged at least 20 years, had an informal caregiver, and were assessed by clinic staff and interviewer as having adequate stamina to complete the interview. We excluded patient-caregiver dyads in which either the patient or the caregiver refused to participate, met criteria for dementia or delirium (by neurobehavioral cognitive status examination), or did not speak either English or Spanish. Patients participated in a baseline interview in English or Spanish for a $25 (£15; €18) payment at a time that was close to when decisions about chemotherapy were being made. We reviewed medical charts at the time of study enrollment and recorded current use of chemotherapy. Research assistants confirmed patients’ performance status and prognosis of six months or less with physicians. We did not record the number and length of previous and subsequent treatments. After each patient’s death, we conducted a chart review and postmortem interview with the patient’s caregivers to confirm the medical care received at the end of life, the patient’s place of death, and whether the patient died in his or her preferred place of death. Main outcome measures The primary outcomes were end of life treatment and location of death. We determined use of intensive interventions in the last week of life (that is, cardiopulmonary resuscitation, mechanical ventilation, or both) and location of death (intensive care unit, hospital, nursing home, inpatient hospice, or home) through a medical chart review and interviews with caregivers. Secondary outcome measures Survival—We abstracted the time from study enrollment to death from medical charts. Late hospice referrals—We determined the duration of hospice services through chart review and interviews with caregivers. We defined late referrals to a hospice as one week or less before death.11 Attainment of preferred place of death—In postmortem interviews, we asked caregivers, “Do you think that the place of death was where the patient would have most wanted to die?” Patients whose caregivers responded “yes” were designated as having died where they wanted to. Primary independent variable of interest We reviewed medical charts on study enrollment to determine whether patients were receiving chemotherapy, radiation, pain management, or treatment on a clinical trial at the time of enrollment. Patients receiving chemotherapy as any part of their treatment, outside of a clinical trial, were included in the chemotherapy group. Additional covariates measured at baseline Sociodemographic characteristics—Patients reported sex, age, marital status, race/ethnicity, religion, health insurance coverage, and last grade completed in school. Health status measures—We measured patients’ functional status with the Karnofsky score and Eastern Cooperative Oncology Group (ECOG) performance status,18 comorbid medical conditions with the Charlson Comorbidity Index,19 and quality of life with the McGill Quality of Life Index.20. Treatment preferences, terminal illness acknowledgment, coping, communication, and advance care planning—We used validated measures to elicit patients’ preferences for chemotherapy, mechanical ventilation, admission to an intensive care unit near death, and life extending care versus comfort care.21 22 We also assessed patients’ acknowledgment of terminal illness, as this has been associated with higher rates of advance care planning and hospice use.23 The Brief COPE and RCOPE surveys assessed active, emotion focused, maladaptive, and positive religious coping with cancer related stress.24 We also asked patients whether they recalled having an end of life discussion with their physician,11 had a strong therapeutic alliance with their providers,25 and had completed a living will, durable power of attorney, or do not resuscitate order (see web appendix). Statistical analyses We used t test, χ2, and Fisher’s exact statistics, as appropriate, to test for significant associations between patients’ baseline characteristics and the receipt of chemotherapy at study enrollment. We used multiple imputation to impute missing data for items other than the dependent variables (for which no data were missing in our cohort)26; item non-response was less than 14% for all variables. We used propensity score analyses to assess the association between patients who were or were not receiving chemotherapy at the time of enrollment.27 To do the propensity score analysis, we first used logistic regression to assess the association of all measured demographic, clinical, psychosocial, and institutional characteristics with being treated with chemotherapy at baseline. The model included age, sex, marital status, insurance status, education, race/ethnicity, religion, institution, cancer type, Karnofsky and ECOG scores, Charlson Comorbidity Index, McGill Quality of Life Index subscales, patients’ treatment preferences and advance care planning, terminal illness acknowledgment, therapeutic alliance with physicians, end of life discussions, and coping styles. For each patient, we used the regression coefficients and the observed covariates to calculate the propensity to receive chemotherapy at study enrollment and derived individual weights equal to the probability of belonging to the opposite group (that is, not receiving chemotherapy).11 28 Thus, after propensity adjustment the weighted distribution of characteristics in both groups were balanced. We then used a generalized linear regression model with an identity link function and a binomial distribution, with the propensity weighted cohorts, to estimate the association of chemotherapy with binary outcomes (for example, cardiopulmonary resuscitation and/or mechanical ventilation). Our events were rare, so we calculated and reported our results as adjusted risk differences as odds ratios may exaggerate the actual risk. We did a sensitivity analysis to examine the effect of excluding covariates that might change over time (Karnofsky score, ECOG score, McGill Quality of Life scales, treatment preferences, and terminal illness awareness), as the exact date of starting palliative chemotherapy was not ascertained during the baseline assessment. We used Cox proportional hazard models to compare the overall survival of patients who were receiving palliative chemotherapy with those who were not, with adjustment for propensity weights. We used SOLAS for Missing Data Analysis version 4.0 for multiple imputation and SAS version 9.2 for statistical analyses. We present two sided P values without adjustment for multiple comparisons; we considered P<0.05 to be significant.

 Results The cohort consisted of 386 terminally ill cancer patients who died a median of 4.0 (interquartile range 1.8-8.3) months after enrollment in the study. Overall, 56.0% of participants were receiving palliative chemotherapy on study enrollment. As shown in table 1⇓, patients who were receiving palliative chemotherapy were more likely to be younger, married, insured, and better educated and to have better performance status, overall quality of life, physical functioning, and psychological wellbeing compared with patients who were not receiving chemotherapy (all P≤0.04). They were also more likely to express a preference to receive “life extending” care over comfort care (39% v 26%, P=0.01), including chemotherapy if it might extend their life by one week (86% v 60%, P<0.001), compared with those not receiving chemotherapy. Table 1 Participants’ characteristics by chemotherapy at study enrollment. Values are numbers (percentages) unless stated otherwise View this table: Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal (35% v 49%, P=0.04) and to report having discussed their end of life wishes with a physician (37% v 48%, P=0.03), compared with those who were not. They were also less likely to have completed a do not resuscitate order (36% v 49%, P<0.05). Propensity score weighting successfully balanced all of the observed differences in patients’ characteristics between the two groups (table 1⇑). In propensity score weighted analyses, receipt of chemotherapy at enrollment was associated with significantly more intensive medical interventions near death. As shown in table 2⇓, patients receiving palliative chemotherapy were more likely to receive cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) compared with those who were not. Chemotherapy use was also associated with higher rates of use of a feeding tube in the last week (11% v 5%; adjusted risk difference 7.1%, 1.7% to 12.5%) and of late hospice referrals (54% v 37% enrolled within one week of death; 13.6%, 3.6% to 23.6%). In adjusted Cox proportional hazards models, we found no significant difference in overall survival between patients who were receiving palliative chemotherapy at study enrollment and those who were not (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). In a secondary model, we assessed the association between receipt of palliative chemotherapy and the intensity of end of life medical care without including characteristics that might have changed since the decision to start palliative chemotherapy was made (that is, performance status, quality of life, treatment preferences, and terminal illness acknowledgment), and the results did not change. Table 2 Associations between chemotherapy at study enrollment and intensity of end of life care. Values are numbers (percentages) unless stated otherwise View this table: As shown in table 3⇓, patients who received chemotherapy at enrollment were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; −10.8%, −1.0% to −20.6%), compared with those who were not. Patients who were receiving palliative chemotherapy on study enrollment were also less likely die in their preferred place, compared with those who were not (68% v 80%; adjusted risk difference −9.4%, −0.8% to −18.1%). In a second model, we examined the association between palliative chemotherapy and patients’ place of death without including characteristics that might change over time; our results were consistent, except that patients’ likelihood of dying in their preferred place was no longer statistically significant (P=0.07). Table 3 Associations between chemotherapy at study enrollment, place of death, and attainment of preferred place of death. Values are numbers (percentages) unless stated otherwise View this table:

 Discussion Our results suggest that terminally ill patients with advanced cancers who receive chemotherapy a few months before death are more likely to receive intensive care at the end of life, compared with patients who do not. In this study, the use of chemotherapy a median of 4.0 months before death was associated with an increased risk of undergoing mechanical ventilation, cardiopulmonary resuscitation, or both in the last week of life and of being referred to a hospice late, both of which have been associated with worse quality of life for patients at the end of life,11 29 30 more distress in bereaved caregivers, 11 29 and higher costs.31 The use of palliative chemotherapy was also associated with an increased risk of dying in an intensive care unit, a decreased likelihood of dying at home, and a lower likelihood that patients died in their preferred place. Comparison with other studies This is the first study, to our knowledge, to examine the associations between the use of palliative chemotherapy and patients’ location of death. Whereas previous studies have identified patient, caregiver, and system level factors that influence where cancer patients die,32 33 34 few have focused on how the care that terminally ill cancer patients receive in the final months of life relates to their place of death outside of hospice or palliative care settings.35 In this study, only a minority of terminally ill cancer patients preferred life extending medical care over care that focused on relieving pain and discomfort. However, more than half wanted chemotherapy if it would extend their life by one week, including 60% of patients who were not receiving chemotherapy. This finding is consistent with previous studies that have shown that many cancer patients are willing to undergo significant treatment related toxicities for small objective benefits.36 37 The one week survival threshold for chemotherapy that we observed is significantly lower than the four to five month thresholds previously reported in similar populations of patients,37 38 39 and it suggests that cancer patients may not regard chemotherapy as burdensome because they are willing to receive it for very limited temporal pay-off. Our findings also underscore the challenge that many oncologists face when discussing the option of stopping chemotherapy with patients and their caregivers,40 particularly when patients—and physicians—may equate stopping treatment with “giving up” or “doing nothing.”41 42 In this study, we observed significant differences in the rates of use of chemotherapy by institution, although they were balanced after propensity weighting and therefore did not influence the observed associations between receipt of chemotherapy and patients’ end of life medical care and place of death. Although our study could not directly compare the relative influences of patient, provider, and institution level factors, we suspect that a combination of these factors explains the differences observed. Future studies should examine the most important determinants of end of life use of chemotherapy. In this study, we did not observe a difference in survival between patients who received palliative chemotherapy and those who did not. This should not be interpreted as evidence that palliative chemotherapy is futile in terminally ill cancer patients, as our analysis was limited to small sample of decedents and may have excluded patients who benefited most from chemotherapy. Instead, this finding should serve as a reminder that palliative chemotherapy does not necessarily extend life, but is associated with more intensive end of life care and increased risk of dying in an intensive care unit, so continuing treatment should not come at the cost of engaging in advance care planning.14 15 Strengths and limitations This study has several important strengths. Previous studies have found that older patients who received chemotherapy within two weeks of death had higher rates of emergency department visits and hospital admissions and decreased hospice use at the end of life.6 7 43 Our data, collected more than a decade later, extend these results by examining associations between palliative chemotherapy given months before death, at the time when most decision making about chemotherapy occurs, and the intensity of patients’ end of life medical care and place of death. Our study may also be more representative of the care provided to “dying patients” than previous work because it enrolled patients of all ages who were prospectively identified by their physicians as terminally ill with a prognosis of six months or less to live.44 45 In addition, we had comprehensive data on patients’ performance status, physical functioning, quality of life, and many other psychosocial factors associated with end of life decision making, including patients’ treatment preferences, awareness of terminal illness, and end of life discussions with physicians,11 22 23 46 which are rarely available in other databases. The study also has limitations. Most notably, we did not have any information about the timing or nature of patients’ decisions about treatment after study enrollment, except for the last week of life. However, subsequent decisions to resume or stop chemotherapy would minimize differences between the two groups, making detection of the effects observed less likely. Despite this, we observed significant associations between the use of palliative chemotherapy and the intensity of patients’ end of life care and place of death, and our results did not change when we removed characteristics that often change in response to chemotherapy (such as quality of life and performance status) or disease progression (such as treatment preferences and awareness of terminal illness). However, the association between receipt of palliative chemotherapy and patients’ preferred place of death became marginally significant in sensitivity analyses and when we included additional covariates in propensity weighted models; thus, future studies should confirm these results in larger populations. In addition, we did not have information about patients’ baseline preferences for the timing of referral to a hospice or place of death. Although short hospice stays—and treatment in an intensive care unit near death—may be viewed as beneficial to dying patients or their family caregivers,47 our previous work suggests that for most patients these outcomes are associated with worse quality of life for patients and more distress in family caregivers six months after bereavement.11 29 In addition, we did not randomize patients to receive palliative chemotherapy or not. Whereas propensity score weighting can effectively adjust for observed differences, it can adjust for unobserved confounders only if they are associated with observed confounders. Furthermore, patients who were receiving chemotherapy at enrollment may have differed in unmeasured ways from those who were not receiving chemotherapy (for example, in their disease duration or previous experiences with chemotherapy). Finally, our analyses were limited to deceased patients who died in 2008, and only a small proportion of our patients experienced the end of life outcomes of interest. Nevertheless, the frequency of events we observed is comparable to or higher than those from population based studies using the most recent Medicare claims available. For example, Teno et al found that 6.7% of cancer patients received mechanical ventilation in the last month of life in 2009.48 In our study, 8.5% of terminally ill cancer patients received mechanical ventilation or cardiopulmonary resuscitation in the last week of life, but a significant difference existed between groups (13.9% v 1.6%) based on exposure to chemotherapy at baseline. Furthermore, we expect that our findings may be a conservative estimate, as Teno et al also found that the intensity of medical care near death is increasing over time.48 Conclusions and policy implications Our results suggest that less use of palliative chemotherapy among patients recognized to have a life expectancy of six months or less—or more frequent end of life discussions in this group—may reduce intensive end of life care and promote earlier access to hospice services, thus improving the quality of advanced cancer patients’ end of life care. Future studies should determine the mechanisms by which palliative chemotherapy is associated with increased risk of receiving intensive care at the end of life and dying in an intensive care unit and examine explicitly whether palliative chemotherapy is associated with patients’ goal attainment. Our study has important implications for oncology providers, patients with advanced cancer, and caregivers facing decisions about treatment. It suggests that end of life discussions may be particularly important for patients receiving palliative chemotherapy, who should be informed by data on the likely outcomes associated with its use. The findings also suggest the need for oncology providers to elicit patients’ preferred site of death to ensure that patients’ end of life experiences are congruent with their values. What is already known on this topic Many patients with metastatic cancer receive chemotherapy in the final months of life, but most are not provided with information on the likely effect on their survival, future care and quality of life, and location of death

 Retrospective, population based studies suggest that cancer patients who receive chemotherapy within two weeks of death are less likely to receive hospice services, compared with those who do not

 Few studies have examined prospectively whether the use of chemotherapy months before death is associated with terminally ill cancer patients’ end of life medical care and place of death What this study adds The use of chemotherapy in terminally ill adult cancer patients in the final months of life is associated with increased risk of undergoing intensive medical care near death and dying in an intensive care unit

 Cancer patients, caregivers, and oncologists should have a heightened awareness about the potential risks of continuing palliative chemotherapy near death

 Advance care planning is needed to ensure that patients’ end of life experiences are congruent with their values

 Notes Cite this as: BMJ 2014;348:g1219

 Footnotes Contributors: AAW and HGP were responsible for the study concept and design. AAW, HGP BZ, NLK, and JCW analyzed and interpreted the data. AAW drafted the manuscript and all authors revised it for important intellectual content. AAW, BZ, NLK, and HGP approved the final manuscript, had full access to all of the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. HGP is the guarantor.

 Funding: HGP has received research grants MH63892 from the National Institute of Mental Health and CA 106370 and CA 156732 from the National Cancer Institute; AAW has received research grants 1K07 CA166210 from the National Cancer Institute and MRSG-13-013 from the American Cancer Society and a Conquer Cancer Foundation of American Society for Clinical Oncology Career Development Award; NLK received research grant 1R01 CA164021 from the National Cancer Institute. The funding organizations had no role in the design and conduct of the study; collection, analysis, or preparation of the data; or preparation, review, or approval of the manuscript. Any opinions, findings, and conclusions expressed in this material are those of the authors and do not necessarily reflect those of the American Cancer Society, the American Society of Clinical Oncology, or the Conquer Cancer Foundation.

 Competing interests: All authors have completed the ICJME uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: HGP has received research grants from the National Institute of Mental Health and the National Cancer Institute; AAW has received research grants from the National Cancer Institute and the American Cancer Society and a Conquer Cancer Foundation of American Society for Clinical Oncology Career Development Award; NLK received a research grant from the National Cancer Institute; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influence the submitted work. ||||| With the death last week of Yale surgeon Dr. Sherwin Nuland, the New York Times obituary credited his 1993 best-selling book, “How We Die,” with being the catalyst that spurred many conversations about end-of-life care.

 Yet 20 years later, many doctors still have a hard time initiating such conversations with their patients, especially those dying before their time from, say, metastatic cancer. Evidence of this comes from a troubling new Dana-Farber Cancer Institute study, which found that more than half of end-stage cancer patients receive chemotherapy during the last few months of their life, and those who received such treatment were more likely to die in a hospital intensive care unit, hooked to a ventilator, rather than at home as they would have preferred.

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 These patients were also less likely to have discussed their end of life wishes with their oncologist compared with other end-stage cancer patients who opted not to continue chemotherapy, according to the study of 386 terminally ill cancer patients published last Tuesday in the British Medical Journal.

 “There’s a subtle dance that happens between oncologist and patient,” said study leader Dr. Alexi Wright, “where doctors don’t want to broach the subject of dying because it makes those patients think we’re giving up on them.”

 She and her colleagues found that chemotherapy didn’t prolong survival but did increase the likelihood of a more medicalized death: 65 percent of those on cancer drugs died in their preferred place compared with 80 percent of those who stopped treatments. ||||| Cancer patients who received chemo were more likely to die in a hospital intensive care unit rather than at home. (credit: Toni L. Sandys/Getty Images)

 ATLANTA (CBS Atlanta) – More than half of end-stage cancer patients receive chemotherapy during the last few months of their life, and those who received such treatment were more likely to die in a hospital intensive care unit, hooked to a ventilator, rather than at home as they would have preferred, says a new study.

 Patients were also less likely to have discussed their end of life wishes with their oncologist compared to other end-stage cancer patients who opted not to continue chemotherapy.

 Researchers say doctors have a hard time initiating conversations with their patients, especially those dying from metastatic cancer.

 “There’s a subtle dance that happens between oncologist and patient,” Dr. Alexi Wright, an assistant professor of medicine at Dana-Farber Cancer Institute, and the study’s lead author, told the Boston Globe. “Where doctors don’t want to broach the subject of dying, especially in younger patients, because it makes those patients think we’re giving up on them.”

 Wright and her team of researchers studied 386 terminally ill cancer patients. They found that the 56 percent that had chemotherapy tended to be younger, better educated, richer, and more optimistic about their prognosis.

 The patients died within an average of four months after participating in the study.

 Sixty-five percent died in their preferred place; as compared to 80 percent of those who chose to stop treatments. The researchers found that those taking chemotherapy were more likely to die in a hospital intensive care unit rather than at home and were more likely to get placed on a ventilator. Most were referred to hospice within a week of their death.

 “Doctors are human beings,” Wright said. “And sometimes we fail to have the clarity to determine when our patients are dying. Andy even when we do, we may not want to give up on treatments as this study suggests is the case.”

 Wright is hoping this study will make more doctors aware that patients who receive chemotherapy may get a false sense of hope and be denied a more peaceful death.

 The study was published in this week’s edition of the British Medical Journal.

 (TM and © Copyright 2014 CBS Radio Inc. and its relevant subsidiaries. CBS RADIO and EYE Logo TM and Copyright 2014 CBS Broadcasting Inc. Used under license. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed) |||||Summary:

– Sad news for cancer patients: A new study finds that those who receive chemotherapy during the end stages of the disease are at a higher risk of enduring a less peaceful death. Of 386 terminally ill patients in a new study, 65% of those who received chemotherapy during the final few months of their life died in their preferred place (for example, at home as opposed to in a hospital). But 80% of those who had chosen to stop treatment died in their preferred location, CBS News reports. Those who continued chemotherapy were more likely to die in an intensive care unit, to undergo CPR, and to be placed on a ventilator. Those who continued treatment were also less likely to have discussed their end-of-life wishes with their doctors. "There’s a subtle dance that happens between oncologist and patient," the lead author explains to the Boston Globe. "Doctors don’t want to broach the subject of dying, especially in younger patients, because it makes those patients think we’re giving up on them." Of the subjects, who died within an average of four months after the study, 56% continued chemotherapy—and they tended to be younger, wealthier, more educated, and more optimistic about their chances of survival. The lead author thinks chemotherapy may give end-stage patients a false sense of hope.


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Editor's Note: This story has been updated with new forecast information.

 It’s been a tough winter for snow lovers. From Chicago to New England, February was actually hot in many parts of country. Daffodils and flowering trees have been blooming for weeks . So far in 2017, it’s been in the 60s or 70s as often as it’s snowed in New York City.

 That’s all about to change this week.

 One of the biggest March snowstorms on record appears poised to strike the East Coast on Monday night, packing strong winds and snow drifts measured in feet. It’s as if Mother Nature decided to make up for lost time and pack an entire season’s worth of winter into a single day.

 A blizzard warning is now in effect for a large swath of the Northeast from Philadelphia to Portland, Maine, including New York City — meaning white-out conditions and tropical-storm-force winds are likely. A relatively sharp cutoff between snow and slush should keep the biggest snow totals away from Washington, D.C. and Boston, but elsewhere, totals will rack up to 1 or 2 feet. The latest National Weather Service forecasts show a wide section of the Northeast, from Maryland to Maine , on tap for more than a foot of snow. Snowflakes should start Monday evening around Washington, D.C. and reach their peak early morning on Tuesday in New York City before tapering off by Tuesday evening across New England. The storm will be a relatively fast-mover, with most of its energy concentrated into a period of about nine hours of heavy snow and strong winds at each location.

 Besides heavy snow and strong winds gusting to nearly hurricane-force in parts of Massachusetts, the storm may bring at least moderate coastal flooding to parts of the New Jersey shore. The result will be a snow day for sure on Tuesday with schools and workplaces closed—the National Weather Service is warning that “several roads may become impassable” and those that travel should bring along a “winter survival kit.” NYC schools will be closed; the governor of Connecticut has issued a statewide travel ban. With leaves already out due to the early spring, there’s also a risk of widespread power outages . An experimental winter storm severity index used by the National Weather Service maxes out the scale:

 While the effects on land may be astounding for at least a short while—words like paralyzing and crippling are being used to describe it—meteorologists are also viewing the storm as eye candy and refer to its weather maps as “ art. ”

 From a weather nerd-out standpoint, the storm is close to perfection. The primary ingredients—a cold pulse from the Great Lakes and a low-pressure system forming off the Carolinas—will pull in subtropical moisture from a record-warm Gulf Stream right offshore . The storm will rapidly strengthen —in the process becoming a meteorological “bomb ” ( a technical term for rapidly strengthening low-pressure centers)—and travel over the sweet spot to maximize snowfall for New York City and New England. That’s forced meteorologists to add new colors to their weather maps, and marvel at an “ absolute crusher ” that will be “ puking snow .” An objective pattern-matching algorithm has compared this storm to some of the all-time strongest, too, including the Valentine’s Day 2007 blizzard and 1993’s “Storm of the Century.”

 There’s even a good chance of thundersnow—the meteorological Holy Grail, made infamous by a viral Weather Channel video from 2011 in Chicago.

 If you’re wondering, “but, it’s March—how is this happening?”—that’s a good question. If the current forecast—which was boosted early Monday morning by the National Weather Service—pans out, the storm will rank as the second-biggest March snowstorm in New York City history (records go back to 1869). Two studies published last year argue that climate change may be making the ingredients for big East Coast snowstorms more likely, and the evidence is starting to mount: Including this storm, eight of the 10 biggest snowstorms in New York City have occurred since 1996. High-resolution weather models continue to insist that most of this storm’s snowfall will come during just a few hours via an intense band with snowfall rates of up to 5 inches per hour—near the upper limit of what is physically possible along the East Coast. ||||| FILE- In this March 10, 2017, file photo, pedestrians walk through wet snow in the Brooklyn borough of New York. The Northeast is bracing for winter's last hurrah — a blizzard expected to sweep the New... (Associated Press)

 FILE- In this March 10, 2017, file photo, pedestrians walk through wet snow in the Brooklyn borough of New York. The Northeast is bracing for winter's last hurrah — a blizzard expected to sweep the New York region starting Monday, March 13, with possibly of being the season's biggest snowstorm. (AP... (Associated Press)

 NEW YORK (AP) — A powerful nor'easter could bring blizzard conditions and more than a foot of snow to some parts of the Northeast, proving that winter is not done yet.

 The National Weather Service issued a blizzard watch from late Monday night through Tuesday evening for New York City and parts of northern New Jersey and southern Connecticut, while winter storm warnings and watches were issued for the remainder of the Northeast.

 Meteorologists said the storm could dump 12 to 18 inches of snow on New York City with wind gusts of 40 to 50 mph.

 Mayor Bill de Blasio urged residents to avoid unnecessary travel and help keep the roads clear for sanitation crews and first responders.

 "We're preparing for a significant storm on Tuesday, and New Yorkers should also prepare for snow and dangerous road conditions," de Blasio said.

 Light snow is expected to begin late Monday night and intensify overnight into early Tuesday morning. The heaviest snowfall is expected Tuesday morning through the afternoon, with snowfall rates of as much as 2 to 4 inches per hour.

 "This would certainly be the biggest snowstorm of the 2017 winter season in New York City," said Faye Barthold, a weather service meteorologist based on Long Island.

 Boston also could get 12 to 18 inches, with isolated amounts of up to 2 feet across northeastern Massachusetts.

 In Philadelphia, crews began treating some area roadways on Sunday. The city could see 6 to 12 inches of snow. The weather service said there is a chance the snow could change over to a wintry mix or rain for a time Tuesday morning, which could limit total snowfall amounts.

 Farther south, in the nation's capital, where the National Cherry Blossom Festival is scheduled to start Wednesday, snow accumulations of 6 to 10 inches are expected.

 Winter's last hurrah arrives just a week after the region saw temperatures climb in the 60s. |||||

– Residents of the Northeast have known that a storm was on the way for days now, but the forecasts are only getting more dire as the moment approaches. The National Weather Service has issued a blizzard watch from late Monday through Tuesday evening for New York City and parts of northern New Jersey and southern Connecticut, while winter storm warnings and watches were issued for the remainder of the Northeast, per the AP. Meteorologists said the storm could dump 12 to 18 inches of snow on New York City and Boston, with Philadelphia is expecting up to a foot. But as NBC News notes, the more dangerous component will be high winds on Tuesday morning, with gusts of 55mph to 70mph in the forecast. "This would certainly be the biggest snowstorm of the 2017 winter season in New York City," says a weather service meteorologist based on Long Island. In fact, it has the potential to be among the worst, if not the worst, March snowstorm in New York City history. Coastal flooding also is a risk along the Jersey shore and elsewhere, as is "thundersnow," explains the Daily Beast. Meanwhile, spring officially arrives on March 20.


Write a summary based on this article:

(CNN) -- It was three years ago that people across the nation and around the world held their breath.

 After a two-month trial, the jury in the Casey Anthony murder trial announced they had arrived at a verdict.

 Anthony was found not guilty of first-degree murder and the other most serious charges against her in the 2008 death of her 2-year-old daughter.

 The nation was first introduced to Casey Anthony in July 2008. The country fell in love with her precious daughter, Caylee, who had gone missing in Orlando, Florida.

 A massive missing persons search for the little girl ensued.

 Police were suspicious of what Anthony, then 22, was telling them. She lied about her nanny taking the child. She lied about working at Universal Studios.

 Anthony suddenly became the most hated woman in America.

 On July 16, 2008, Anthony was arrested on suspicion of child neglect. Her attorney was an unknown Florida lawyer named Jose Baez. A Florida grand jury indicted Anthony on capital murder charges October 14, 2008. A utility worker found Caylee's skeletal remains in a wooded area near the Anthony home in December 2008, and several months later, prosecutors announced they would seek the death penalty.

 Florida v. Casey Anthony: A look back at evidence and testimony

 Watching in the wings was another Florida lawyer, Cheney Mason. A former president of the Florida Association of Criminal Lawyers, Mason, who just that year had been selected by Florida Monthly magazine as one of Florida's top lawyers, was disgusted with the local media coverage about the relatively inexperienced Baez.

 "I was offended by it. I was offended by the fact that he wasn't being treated fairly. I didn't know Baez. I had never met him," Mason said.

 Baez started asking Mason, a Florida death penalty qualified attorney, for advice. That propelled Mason to want to meet Anthony. He remembers going to the Orange County jail to introduce himself.

 "They brought her to the room, and I have to tell you I was really surprised to see how small she is ... how tiny she is. I stood looking at a child herself. I said this can't be," he said.

 I sat down with Mason exclusively to talk with him about his new book, "Justice in America." In it, he insists that the jury got it right, and the rest of the country had it wrong.

 "Could she look you in the eye?" I asked.

 "Oh yes," Mason responded, describing her demeanor as quiet, afraid and unsure.

 After that meeting, with Anthony's approval, Mason decided to join the team pro bono. He said the unpaid time he spent on the case "was well over a million dollars" and cost him tens of thousands of dollars out-of-pocket.

 Mason said in the years before trial, he normally met with Anthony in a lunch room at the jail. The jail would clear everyone out before Anthony came in. A stationary video camera in the room was positioned on their conversations, so he and Anthony would cover their mouths and speak in low tones to each other, Mason said.

 Shortly before jury selection was to begin, Mason got word that Anthony's handwritten letters describing sexual abuse at the hands of her father were going to be made public under Florida's open records law.

 He believed it was only right that Anthony's parents, George and Cindy, were warned. He called them to his office late on a Friday afternoon.

 "We had them one at a time come into my personal office and made the announcement: 'Monday's going to be a bad day for you George. I felt man to man I would tell you in advance.""

 Mason said George Anthony's reaction was "basically none." "He looked at me ... I turned sideways a little bit, he clapped his hands down on his thighs -- let out a big sigh but didn't say anything," Mason said.

 "He never admitted doing anything," Mason said. "All we had were the letters and (separately) the statements Casey had made to the psychiatrist."

 Next it was Cindy Anthony's turn. "We called Mom in, Cindy, and told her and she immediately welled up with emotion, cried, was very upset," Mason said.

 Once a jury was selected it was time for the evidentiary portion of the trial. Baez gave the opening statements. In the midst of telling the jury what the evidence would show, he delivered a bombshell that turned the case on its head by telling the jury that his client was a victim of sexual abuse by her father.

 The country was stunned and so was Mason, who was sitting next to Anthony in the courtroom.

 "I didn't know that he was going to say that. We had talked about all aspects of it, and I did not know. I don't know if anybody knew that he was going to say that other than himself," Mason recalled.

 I asked Mason if he was concerned the defense would not be able to establish this with evidence as promised during the opening statement. Mason said he was.

 "Yes, I was concerned about that because I knew we didn't have the ability to prove that unless George got on the stand and confessed," he said.

 The prosecution responded by making George Anthony its first witness. The first question Assistant State Attorney Jeff Ashton asked him was whether he had sexually abused his daughter. George Anthony responded with a definitive no.

 The trial went on for weeks. Witness after witness took the stand for the prosecution in the largely circumstantial case. They finally rested their case on June 15, 2011. Then it was the defense's turn.

 Anthony's defense attorneys maintained that Caylee was not murdered at all. They said the child drowned in the Anthony's above-ground pool, and that Casey Anthony and her father panicked upon finding her there and covered up the death. George Anthony denied that in his testimony.

 Casey Anthony: 'I didn't kill my daughter'

 In the midst of the defense case, Mason described how out-of-court conversations with the prosecution suddenly turned to possible plea discussions. Anthony was approached with the possibility.

 "Casey got very angry about that. She got very angry to hear talk about it. She didn't want to hear it." Mason said. "Casey would fight it 'til her last breath. She didn't kill her daughter."

 Mason said he believes it took a lot of courage and strength for Anthony to end any talk of a plea agreement. She knew what was at stake in this death penalty trial.

 So, plea discussions were stopped in their tracks, Mason said, and the trial went on.

 Then, on July 5, 2011, after deliberating for 10 hours, jurors announced they had reached a verdict.

 "She was holding her breath like a deep sea diver, waiting as we all were," Mason said.

 Anthony was acquitted by the 12-person jury on the most serious charges, including first-degree murder, aggravated child abuse and aggravated manslaughter of a child. But the jury convicted her on four misdemeanors of providing false information to law enforcement officers.

 Anthony now lives in an undisclosed location in Florida and doesn't go out of the home she is living in because of the public hate and continued threats to her life, Mason said.

 "She has to live constantly on guard. She can't go out in public," Mason said.

 By her own choice, she works inside the home, Mason said, and is living as "a housekeeper, clerk, secretary and stuff like that."

 "I think Casey has a lot of world left to have to deal with. She hasn't been freed from her incarceration yet 'cause she can't go out. She can't go to a beauty parlor, she can't go shopping to a department store, she can't go to a restaurant, she can't even go to McDonald's. She can't do anything," he said.

 Mason and his wife, Shirley, have continued a relationship with Anthony. Now three years after being acquitted, Mason said Anthony still distrusts the outside world.

 "Casey is aloof," Mason said. "She is kind of, I think, afraid of people ... she's not real close to. We've had a couple of occasions to have social gatherings that can include her -- close friends, the (legal) team. She still likes to back away from the middle."

 2012: Anthony's 'video diary' surfaces

 Anthony "does not have any blood family anymore," Mason said. The family she has is the residual of the defense team, Dorothy Clay Sims, Lisabeth Fryer and Mason's wife.

 Mason said although there may have been a few conversations between Anthony and her mother in recent years, there is no relationship.

 And as for a relationship with her father? "None," Mason said emphatically.

 Shirley Mason has also gotten to know Anthony over the past three years.

 "I'm a cross between a friend, a mother, but not a mother -- only someone who is older who has had experience in the world she has not had," she said.

 Mason gives Anthony advice, but also listens to her when they talk.

 "My hope for her is it gets better for her and the world or the people who have been so hateful can let that go and they can move on," she said.

 Anthony "tries to make her life work," Shirley Mason said. She takes care of herself and stays physically fit by working out in the house.

 "I do think she wants to speak out," Mason said. Anthony declined CNN's request for an interview.

 "I have never asked her that, but I know she has very strong feelings for what has happened to her. I also know she's very saddened by her loss and she will never forget her daughter Caylee, ever." ||||| In promoting his new book about the Casey Anthony trial, Orlando defense attorney J. Cheney Mason told CNN on Thursday that his former client is essentially still imprisoned because of the public's hatred toward her.

 Mason told CNN that Anthony, who was exonerated in her daughter's death three years ago, is doing some clerical work and legal research.

 He didn't disclose where Anthony is living, but said she does not live alone and is not dating.

 Mason said the public hasn't had a chance to meet the real Casey Anthony.

 The veteran attorney's new book, "Justice in America: How Prosecutors and the Media Conspire Against the Accused," is slated to be released this summer.

 The e-book will be available Monday and the book will be released Aug. 18, according to the publisher.

 Mason told the Orlando Sentinel the book is about the Anthony trial and legal issues surrounding the high-profile case.

 Mason is the third attorney associated with the Anthony case to author a book about the 2011 trial, and said his reveals many things the others did not.

 "This is not a book about me," Mason told the Sentinel. "It's not a book solely about Casey, by any means."

 Mason said his book addresses legal issues, the impact of the media and bias in the court, and will include copies of motions filed in the case.

 The book will also provide behind-the-scenes information that the media and public weren't privy to.

 According to a summary of the book on amazon.com, Mason "shares never before revealed media bias, and enough case secrets to make readers re-examine their conscience and the quick path to judgment and personal conviction of Anthony."

 Mason's co-counsel on the Anthony trial, attorney Jose Baez, and prosecutor Jeff Ashton each penned best-selling books about the case.

 Mason said he will make public appearances to promote the book, but no dates have yet been scheduled.

 apavuk@tribune.com or 407-420-5735 |||||

– It has been almost exactly three years since Casey Anthony was found not guilty of murdering her 2-year-old daughter Caylee, but she is still essentially a prisoner, one of her lawyers says. Anthony, now 28, lives in an unnamed location in Florida and remains afraid to go out in public because of death threats, Cheney Mason tells CNN. She does clerical work at home for various clients, but "she hasn't been freed from her incarceration yet 'cause she can't go out," the lawyer says. "She can't go to a beauty parlor, she can't go shopping to a department store, she can't go to a restaurant, she can't even go to McDonald's. She can't do anything." The Orlando Sentinel notes that Mason says Anthony doesn't live alone, and isn't romantically involved with anyone. Anthony—who accused her father of sexually abusing her—"does not have any blood family anymore" and the family she has now consists of members of her defense team. Mason says he thinks she "wants to speak out"; Anthony declined CNN's request for an interview, however. "I know she has very strong feelings for what has happened to her. I also know she's very saddened by her loss and she will never forget her daughter Caylee, ever," Mason says. His book, Justice in America: How Prosecutors and the Media Conspire Against the Accused, will be released this summer. Mason—the third attorney associated with the case to write a book—says it will include information never revealed before, and will go beyond the Anthony case to explore broader legal issues.


– House Democratic leader Nancy Pelosi on Thursday rejected the idea of paying for President Trump's border wall in exchange for helping hundreds of thousands of young immigrants avoid deportation. Funding for the wall—a top Trump priority—and legal protections for so-called Dreamers, a key Democratic goal, should not be linked, Pelosi said. "They're two different subjects," and most Democrats consider the wall "immoral, ineffective, and expensive," Pelosi said. Her comments came as the House and Senate approved a stopgap bill Thursday to keep the government funded through Dec. 21, the AP reports. The measure, approved by voice votes in near-empty chambers, now goes to the White House. Trump has promised to sign the two-week extension to allow for ceremonies this week honoring former President George HW Bush, who died Nov. 30. But he wants the next funding package to include at least $5 billion for his proposed wall, something Democrats have rejected. Trump is set to meet Tuesday at the White House with Pelosi and Senate Democratic leader Chuck Schumer. Schumer said Thursday that a bipartisan Senate plan for $1.6 billion in border security funding does not include money for the 30-foot-high concrete wall Trump has envisioned. In a tweet late Thursday, Trump warned of the potential for "Big danger" at the US-Mexico border in Arizona, demanding, "Nancy and Chuck must approve Boarder Security and the Wall!" (Trump says he is "totally willing" to shut down the government if funding for the wall is not approved.)

Expand this summary.

House Democratic Leader Nancy Pelosi of California, meets with reporters at her weekly news conference on Capitol Hill in Washington, Thursday, Dec. 6, 2018. (AP Photo/J. Scott Applewhite) (Associated Press)

 House Democratic Leader Nancy Pelosi of California, meets with reporters at her weekly news conference on Capitol Hill in Washington, Thursday, Dec. 6, 2018. (AP Photo/J. Scott Applewhite) (Associated Press)

 House Democratic Leader Nancy Pelosi of California, meets with reporters at her weekly news conference on Capitol Hill in Washington, Thursday, Dec. 6, 2018. (AP Photo/J. Scott Applewhite) (Associated Press) House Democratic Leader Nancy Pelosi of California, meets with reporters at her weekly news conference on Capitol Hill in Washington, Thursday, Dec. 6, 2018. (AP Photo/J. Scott Applewhite) (Associated Press)

 WASHINGTON (AP) — House Democratic leader Nancy Pelosi on Thursday rejected the idea of paying for President Donald Trump's border wall in exchange for helping hundreds of thousands of young immigrants avoid deportation.

 Funding for the wall — a top Trump priority — and legal protections for so-called Dreamers, a key Democratic goal, should not be linked, Pelosi said.

 "They're two different subjects," she said.

 Her comments came as the House and Senate approved a stopgap bill Thursday to keep the government funded through Dec. 21. The measure, approved by voice votes in near-empty chambers, now goes to the White House.

 Trump has promised to sign the two-week extension to allow for ceremonies this week honoring former President George H.W. Bush, who died Nov. 30. But he wants the next funding package to include at least $5 billion for his proposed wall, something Democrats have rejected. Trump is set to meet Tuesday at the White House with Pelosi and Senate Democratic leader Chuck Schumer.

 In a tweet late Thursday, Trump warned of the potential for "Big danger" at the U.S.-Mexico border in Arizona, demanding, "Nancy and Chuck must approve Boarder Security and the Wall!"

 Pelosi, who is seeking to become House speaker in January, said the lame-duck Congress should now pass a half-dozen government funding bills that key committees have already agreed on, along with a separate measure funding the Department of Homeland Security, which oversees the border. Funding for the homeland agency should address border security and does not necessarily include a wall, Pelosi said.

 Most Democrats consider the wall "immoral, ineffective and expensive," Pelosi said, noting that Trump promised during the 2016 campaign that Mexico would pay for it, an idea Mexican leaders have repeatedly rejected.

 Even if Mexico did pay for the wall, "it's immoral still," Pelosi said.

 Protecting borders "is a responsibility we honor, but we do so by honoring our values as well," she added.

 Schumer said Thursday that a bipartisan Senate plan for $1.6 billion in border security funding does not include money for the 30-foot-high (9-meter-high) concrete wall Trump has envisioned. The money "can only be used for fencing" and technology that experts say is appropriate and makes sense as a security feature, Schumer said.

 If Republicans object to the proposal because of pressure from Trump, Schumer said lawmakers should follow Pelosi's advice and approve six appropriations bills and a separate measure extending current funding for Homeland Security.

 Either option would avert a partial government shutdown, which lawmakers from both parties oppose, he said.

 "The one and only way we approach a shutdown is if President Trump refuses both of our proposals and demands $5 billion or more for a border wall," Schumer said. He called the wall "a nonstarter" for Democrats, who face increasing pressure from outside groups and liberal lawmakers to resist Trump's continued push for the barrier, which Trump says is needed to stop an "invasion" of Central American migrants and others from crossing into the country illegally.

 Schumer called the spat over the wall unnecessary, noting that the administration has not spent more than $1 billion approved for border security in the budget year that ended Sept. 30. "The idea that they haven't spent last year's money and they're demanding such a huge amount this year makes no sense at all," he said.

 Senate Appropriations Committee Chairman Richard Shelby said he prefers to include Homeland Security in an omnibus package containing seven unresolved spending bills for the current budget year.

 "I believe the best route is to keep all seven together and pass them," the Alabama Republican told reporters Thursday. Lawmakers have "made a lot of progress" in recent weeks on the seven spending bills. "I'd like to conclude it,'" he said.

 Missouri Sen. Roy Blunt, a member of Republican leadership, said the key question is whether Trump will sign a bill without funding for the wall.

 "It doesn't matter how much appetite there is for a shutdown anywhere else, if he is willing to have a shutdown over this issue," Blunt said. "He has given every indication that he would."

 ___

 Associated Press writers Alan Fram and Padmananda Rama contributed to this story. ||||| Tweet with a location

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Breaking News Emails Get breaking news alerts and special reports. The news and stories that matter, delivered weekday mornings.

 By Tom Winter

 The longtime chief financial officer of the Trump Organization, Allen Weisselberg, was given immunity by federal prosecutors in New York during the course of the Michael Cohen investigation, according to two people with knowledge of the matter.

 The news was first reported Friday by The Wall Street Journal.

 Weisselberg is "Executive 1" on page 17 of the criminal information filed by prosecutors in the Michael Cohen case, a person with knowledge of the matter told NBC News.

 According to prosecutors, Cohen, then Trump's attorney, sent an invoice to Executive 1, meaning Weisselberg, for "Payment for services rendered for the month of January and February, 2017," a payment that was really meant to reimburse Cohen for a payment to Stormy Daniels.

 Weisselberg then sent the invoice to another Trump Organization executive via e-mail directing him to "Please pay from the Trust. Post to legal expenses. Put 'retainer for the months of January and February 2017' in the description."

 A spokesperson for the U.S. Attorney's Office for the Southern District of New York declined comment.

 Weisselberg, 70, began working for the Trump Organization as an accountant in the 1970s, when President Donald Trump's father, Fred, ran the company. Weisselberg was also treasurer of the Donald J. Trump Foundation, the president's charitable organization, which has been sued by the New York attorney general for alleged violations of state law.

 Cohen mentioned Weisselberg's name several times on a recorded phone conversation with Trump about a payment to kill a story about Trump's alleged relationship with Playboy model Karen McDougal. The tape was seized during the FBI's April raid on Cohen's residence and office, and was released to the media by Cohen's attorney, Lanny Davis.

 On the tape, recorded two months before the 2016 presidential election, Cohen mentions that he has spoken to Weisselberg about setting up a corporation to process the payment.

 "I need to open up a company for the transfer of all that info regarding our friend David," says Cohen, "so that — I'm going to do that right away. I have spoken to Allen Weisselberg about how to set the whole thing up with funding."

 "David" is apparently David Pecker, a Trump friend who is the chairman and CEO of American Media and publisher of the National Enquirer, which had agreed to purchase McDougal's story. ||||| President Trump’s former personal attorney Michael Cohen pleaded guilty to eight criminal charges on Tuesday. WSJ’s Shelby Holliday explains how Cohen’s plea agreement could impact the president. Photo: Associated Press

 President Trump’s financial gatekeeper was granted immunity by federal authorities in New York and testified before a grand jury, the third longtime confidant of Mr. Trump known to have provided information in an illegal hush-money investigation that has implicated the president.

 Allen Weisselberg, who has served for decades as chief financial officer and executive vice president of the Trump Organization, testified several weeks ago in the criminal investigation by federal prosecutors in Manhattan into Michael Cohen, Mr.... |||||

Write a summary.

– First Michael Cohen, then David Pecker, and now Allen Weisselberg. Another longtime ally of President Trump has been granted immunity by prosecutors in exchange for testimony. The 70-year-old Weisselberg is no mere acquaintance: He has served for decades as chief financial officer and executive VP of the Trump Organization, reports the Wall Street Journal. In fact, when Trump was elected president, he turned over the financial reins of his business empire to Weisselberg and to Trump's adult sons. Weisselberg actually started working for the organization in the 1970s, when Trump's father, Fred, ran it, per NBC News. Earlier this year, Weisselberg was called to testify before a grand jury as part of the investigation of Cohen's payments to two women in exchange for their silence about alleged affairs with Trump. Weisselberg had been mentioned in a recorded conversation between Cohen and Trump about how to facilitate a payment to former Playboy model Karen McDougal. Cohen has pleaded guilty to eight charges and said Trump directed him to make the hush-money payments ahead of the election, possibly implicating the president in a federal crime. It's not clear what information Weisselberg provided in the investigation. (This week, Trump suggested that "flipping" in exchange for deals with prosecutors should be illegal.)


Article:
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 This will NOT appear anywhere on Newser ||||| Harvey Weinstein accuser Rose McGowan is facing arrest after airport police found traces of narcotics in belongings she left behind at Washington Dulles International Airport after she arrived on a flight from Los Angeles earlier this year. McGowan has accused Weinstein of raping her in 1997, and claims that one of the disgraced producer’s close associates offered her $1 million to remain silent about the assault.

 “Are they trying to silence me?” McGowan tweeted earlier today about the warrant for her arrest. “What a load of horseshit.”

 “Her personal belongings that were left behind from a flight arriving on Jan. 20 tested positive for narcotics,” said Rob Yingling, a spokesman for the Metropolitan Washington Airports Authority Police Department. “Our police have attempted to contact Ms. McGowan so that she can appear in a Loudoun County Virginia court to respond to the charge.” The charge against her, he told Deadline, is a felony.

 Airport police, he said, “have been issued a bench warrant and entered it into a national law enforcement database.”

 “Refusing Weinstein’s hush money, Rose McGowan calls out Hollywood,” she later tweeted. And then, in response to recent allegations against Kevin Spacey – and other uncorroborated allegations against other prominent gay men in Hollywood – she tweeted: “Spacey Singer Spacey Singer Ancier Geffen good afternoon. How are you today?”

 “We are an army of thorns,” she added. |||||Summary:

– Rose McGowan has been among the most vocal in speaking up about Harvey Weinstein. Now she's raising her voice about some trouble she's in with the law, and she's amplifying her outspokenness with a sprinkling of profanity. "Are they trying to silence me? There is a warrant out for my arrest in Virginia. What a load of HORSES---," she tweeted Monday, referencing what a Metropolitan Washington Airports Authority Police Department spokesman tells Deadline is a felony charge against her. That charge apparently involves some of her personal items left behind at Dulles International Airport on Jan. 20 after she flew in from Los Angeles—items cops say contained traces of drugs. "Her personal belongings … tested positive for narcotics," says MWAA rep Rob Yingling. Yingling adds that airport cops have been given a bench warrant for McGowan and that it has been plugged into "a national law enforcement database." The AP notes the MWAA received the warrant on Feb. 1, and cops say they've been trying to touch base with McGowan since so they can get her to make an appearance in Loudon County, Va., to answer the charge. The Washington Post notes that while McGowan hasn't clarified who the "they" is in the alleged silencing attempt, others are piling onto the conspiracy, with one radio host calling it "shockingly transparent retaliation." When writer Ashlee Marie Preston suggested on Twitter that headlines about McGowan's arrest would never have emerged had McGowan taken the $1 million in hush money she alleges Weinstein offered her, the actress retweeted that comment with her own one-word response: "FACT."


Article:
AP Photo 2016 Clinton raises $28 million but Sanders’ haul is too close for comfort

 Democratic front-runner Hillary Clinton’s campaign barely outpaced Bernie Sanders’ in the third quarter of 2015, a surprising development that shows the insurgent candidate’s strength while the former secretary of state struggles.

 Clinton’s operation raised more than $28 million in the third quarter after a grueling fundraising schedule, compared with about $26 million for the Vermonter — who raised his money largely from online donations, and few in-person fundraising events.

 Story Continued Below

 The narrow gap illustrates Sanders’ momentum in the third quarter, as he overtook Clinton in polling in both New Hampshire and Iowa. But Clinton’s overall fundraising machine remains formidable: combined with the $47.5 million she raised in the second quarter, her campaign has brought in roughly $75 million in six months. Sanders, by comparison, raised just $15 million in his first few months.

 While considerably less than her first haul, Clinton's $28 million figure doesn’t come as a huge surprise to her team. The campaign had expected her numbers to drop during the summer months, while she was dogged by questions about her email practices at the State Department and falling poll numbers in the early-voting states.

 "We are thrilled and grateful for the support of hundreds of thousands of donors across the country, helping us raise a record $75 million in the first two quarters," said Clinton's campaign manager Robby Mook in a statement.

 The campaign's joint fundraising committee with the Democratic National Committee and state parties brought in over $3 million, the campaign said.

 But Sanders’ own eye-popping haul — he raised $2.07 million online on Sept 30 alone — gives Democrats reason for pause. Much of the party establishment’s argument against Sanders centers on whether he could stand head to head against a well-funded Republican in the general election. His now-demonstrated fundraising prowess hardly erases such concerns, but it calls the assumption into question.

 Clinton’s allies also take solace in knowing that she has affiliated super PACs with considerable fundraising power, while Sanders refuses to associate with any such groups. Priorities USA Action, the big-money Clinton group, told POLITICO it had raised $40 million so far in 2015 by mid-August.

 Sanders’ campaign said on Wednesday that it had passed the one-million contributor mark in the third quarter, while Clinton’s own operation said that 93 percent of her third-quarter donations came in increments of less than $100.

 The full disclosures for the period that ended Sept. 30 will be released next week, and filings from both contenders will be scrutinized not only for the details about where the money came from but how the campaign then spent it. ||||| Boston (CNN) Hillary Clinton's presidential campaign raised more than $28 million in the third fundraising quarter of 2015, a number only slightly more than the $25 million Bernie Sanders raised.

 Clinton's third quarter fundraising brings her total haul to $75 million, aides said. And while it is less than the $45 million Clinton's campaign raised in the second quarter, it appears the campaign is likely to reach it's $100 million goal by the end of 2015.

 Sanders' fundraising is closing in on Clinton, however, despite only ever headlining seven fundraisers as a candidate. Michael Briggs, Sanders' spokesman, said Wednesday night that the campaign has $25 million cash-on-hand after raising $15 million in the second quarter.

 Clinton and Sanders raised their money in very different ways.

 Read More ||||| With hours to go before the third quarter campaign finance filing deadline, the campaign of Democratic presidential hopeful Bernie Sanders said it reached its goal of one million individual online contributions.

 He is the first candidate of the 2016 campaign to announce it had reached this number – and he reached it faster than President Barack Obama did in 2008 and 2012.

 The Sanders campaign has touted its goal of hitting one million donations by tonight’s deadline to spur more individuals to donate. |||||Summary:

– Bernie Sanders is raising a lot more money than many people expected, and he's doing it a lot faster. His campaign announced just before the Wednesday filing deadline that it has received more than a million online donations, making him the first 2016 candidate to pass that milestone and the first ever to pass it so early, reports the Wall Street Journal, which notes that the Obama campaigns got there in February 2008 and October 2011. According to the filing, Sanders' fundraising is rapidly catching up with Hillary Clinton's, with the Vermont senator raising $25 million in the third quarter of this year, not far off the $28 million his rival raised during the same period, although her second-quarter numbers were much higher, CNN reports. Most of Clinton's cash in the third quarter came from the 58 fundraising events she headlined that asked donors to pay $2,700, CNN reports, while almost all of Sanders' take came from the online operation, which had an average donation of $24.86. But he has had to spend money to make money: The New York Times estimates that the Sanders campaign has already spent $15 million, mostly on hiring staff and on online fundraising, without spending much on commercials or polling. Politico calls his haul "eye-popping" and notes that it undercuts arguments that Sanders couldn't compete with a well-funded Republican. Clinton, however, has affiliated super PACs on her side and Sanders shuns such groups. (Polls show that Clinton is falling behind in New Hampshire.)


A member of the St. Louis County Police Department points his weapon in the direction of a group of protesters in Ferguson, Mo. in August. (AP Photo/Jeff Roberson)

 The Pentagon program that sends excess military equipment to police across the country has been under scrutiny since August, when civil unrest in Ferguson, Mo., came to a head and the tactics of police there came under fire by civil rights advocates. But the controversy appears to have prompted change: after years of declining to do so, the Defense Department has released a detailed breakdown of what it has supplied to police departments.

 The results range from the mundane (battery chargers), to the powerful (armored mine-resistant vehicles), to the surprising (trumpets?). It also includes everything from helicopters to robots designed to help bomb squads.

 The Pentagon’s Excess Property Program, sometimes known as the 1033 Program, has supplied police departments across the country with more than $4.3 billion in gear since 1997, including $449 million in 2013, Pentagon officials said.

 The data was quietly posted on a Freedom of Information Act reading room for the Pentagon’s Defense Logistics Agency on Nov. 21, as the Marshall Project noted today. It’s a significant change in policy: The Defense Department has repeatedly rejected FOIA requests for a full accounting of the 1033 program’s recipients.

 The spreadsheets, captured here for Checkpoint, highlight the sheer volume of equipment the Pentagon is giving away — and that many of the departments receiving it are not big-city departments, but small police forces.

 There are hundreds of organizations that have received armored mine-resistant vehicles, for example. Designed to protect combat troops from gunfire, rockets and roadside bombs, they have been sent to police departments who are ostensibly concerned about terrorism. Recipients include:

 The Val Verde Sheriff Office in Del Rio, Texas, which protects a rural county of about 50,000 people near the Mexico border.

 The Washington Police Department in Iowa, which has 10 sworn officers in a town of about 7,000.

 The Rehoboth Police Department in Massachusetts, which serves a town of about 10,000 along the Rhode Island border.

 The Saddleback College Police in California, which work at a community college.

 Perhaps predictably, among the most common items issued were rifles, both in 5.56mm and 7.62mm caliber. They were supplied to departments large and small in a variety of quantities. Police in Long Beach, Calif., for example, have received 200 5.56mm rifles.

 On the unexpected side: the Los Angeles County Sheriff Department in southern California received 500 pairs of snowshoes, the Clayton Township Police Department in Michigan and the North Kingsville Police Department in Ohio each received a French horn, and more than 372 televisions were supplied to police across the country, designated “for personal/home use.” In Cherokee County, Ala., the sheriff’s department also received 15,000 metal fence posts. Total value: more than $127,000.

 Previously on Checkpoint:

 Pentagon defends program supplying military gear to Ferguson police

 Military gear beyond Ferguson: A look at how the Pentagon’s equipment has spread

 Military veterans see deeply flawed police response in Ferguson

 Video: Breaking down the military gear used by Ferguson police

 Steven Rich contributed to this report. ||||| The gear was listed in data recently released by the department detailing the transfer of surplus military equipment to federal, state and local law enforcement agencies across the country. More than $160 million in equipment has gone to agencies in California, with some small towns like Santa Maria receiving grenade launchers, the data show. The vast majority of the equipment was given since 2006. |||||

Write a summary.

– Just what Los Angeles County police need: 500 snowshoes and 1,600 parkas. Need aside, that's what they were handed by the Defense Department in March, according to a breakdown of $4.3 billion in surplus military supplies sent to police departments across the country since 1997. Think that's bizarre? Some other strange deliveries, per the Los Angeles Times and Washington Post: 86 M14 rifles to the California Department of Fish and Wildlife; grenade launchers to small California communities; French horns for Ohio's North Kingsville Police Department and Michigan's Clayton Township Police Department; a $4.4 million boat to Alameda County police; and 372 TVs, designated "for personal/home use."


Here is a news article: NEW YORK (Reuters) - President Donald Trump’s 90 percent cut to Obamacare advertising has U.S. health insurers in many states digging deeper into their pockets to get the word out about 2018 enrollment, which opened last week.

 FILE PHOTO: A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake/File Photo

 Independence Blue Cross, a health insurer in Pennsylvania, has commissioned a tractor trailer truck to bring insurance consultants out to shopping centers and other neighborhood spots around Philadelphia.

 Centene Corp (CNC.N), best known for its Medicaid health insurance, is expanding TV and print advertising for Obamacare as it ventures into three new states: Kansas, Missouri and Nevada. Tech-savvy newcomer Oscar Health has four different TV commercials running in six states including Texas and Ohio that espouse “easy health insurance” with video shots of patients text-messaging with Oscar.

 Trump cut $90 million in advertising and outreach spending for the 2018 enrollment period, which opened on Nov. 1, part of his promise to let Democratic President Barack Obama’s signature healthcare law “implode” until Congress can repeal it.

 Republicans say the Affordable Care Act, the law that created Obamacare, drives up costs for consumers, while Democrats warn that millions of Americans will be left without healthcare if it is dismantled.

 The advertising serves two roles: It helps draw in the young, healthy customers who keep overall member costs down and it addresses confusion among many people over whether the subsidies that help make coverage affordable to many and Obamacare itself still exist in the wake of Trump’s actions.

 The government’s advertising budget is now just $10 million for the 39 states that rely on the federal Healthcare.gov website to enroll consumers. The 11 states that run their own exchanges, like California and New York, set their own advertising budgets.

 “Our member plans are generally ramping up their efforts to kind of plug that hole,” said Kelley Turek, an executive policy director at industry lobbyist America’s Health Insurance Plans. “A decrease of $90 million is a big hole to plug.”

 News headlines about changes in the government's support of Obamacare and Trump’s tweets have raised fears that all program subsidies are ending. The government has also cut the enrollment period in half, to six weeks. (tmsnrt.rs/2k1HAlV)

 FILE PHOTO: A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake/File Photo

 Adding to the confusion, insurers like Anthem Inc (ANTM.N) have sharply raised monthly premiums on the most popular Obamacare plans to account for reduced government funding, or pulled out of dozens of U.S. counties. As a result, many Obamacare customers may need to change health plans for 2018, either to work with a different insurer or in response to price increases.

 “I still run into people who are wondering, am I still going to have a plan next year?” Independence Blue Cross Chief Executive Officer Daniel Hilferty said in an interview.

 Hilferty said the company is increasing its advertising this year in part because of that confusion.

 IMBALANCED MARKET

 In September, the Congressional Budget Office said it expected 2018 enrollment to reach 11 million people versus about 10 million this year. It cut its previous projection by 4 million as Trump threatened the law and later cut the estimated $10 billion in government subsidies to insurers to cover customer out-of-pocket costs in 2018.

 To make up for the reduced subsidies, which apply to the most common “silver” plans - the middle tier of the plans offered - insurers raised premiums by about 20 percent on those plans.

 Others say total sign-ups will drop. Get America Covered, an outreach group founded by former Obama administration officials, predicts 1.1 million fewer people will sign up during the enrollment period. Lori Lodes, a co-founder of the group, said the effort by insurers focused on local markets could not match the impact of a national campaign.

 Various insurers say they are trying.

 Blue Cross Blue Shield of North Dakota, the sole Obamacare insurer in most of North Dakota, increased online advertising for 2018, while traditional TV and radio advertising remained about flat, spokeswoman Andrea Dinneen said.

 Florida Blue, which has about 1 million members in Obamacare plans throughout Florida, is increasing its grass roots efforts this year. It has hired 700 temporary employees to help with enrollment and is planning to take part in more than 1,000 enrollment events, such as county fairs or educational sessions, spokesman Paul Kluding said.

 On the other hand, Blue Cross Blue Shield of Michigan said it would spend less on wooing customers because of the financial pressures from the lowered subsidies, which went into effect this month. Instead it will focus on helping existing customers select plans that may keep premium costs down, rather than automatically re-enrolling in the silver plans.

 “We decided to try to be as lean as possible,” said Rick Notter, director of the individual business. ||||| A record number of people signed up for ObamaCare in the first few days of open enrollment this year compared to the same period in previous years, several sources close to the process told The Hill.

 The surge in sign-ups, which was confirmed by an administration official, comes despite fears from Democrats that enrollment would fall off due to the Trump administration's cutbacks in outreach and advertising.

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 On the first day of enrollment alone, Nov. 1, one source close to the process told The Hill that more than 200,000 people selected a plan for 2018, compared with about 100,000 last year. More than 1 million people visited healthcare.gov that day, compared to about 750,000 last year, the source said.

 It is still early in the process and it is unclear how the final sign-up numbers will come out. Sign-ups early in the enrollment season are often people renewing their coverage, not new enrollees.

 Standard & Poor’s forecasted last week that enrollment could drop by as much as 1.6 million people below last year’s level of 12.2 million signups, in part due to uncertainty from the administration's actions.

 The enrollment period is also about half as long this year, ending Dec. 15.

 But the spike in sign-ups is some positive news for supporters of the health-care law who have been worrying about its fate under Republican control of Washington.

 “The first few days of Open Enrollment for the Federal Health Insurance Exchange went smoothly," said a spokesperson for the Centers for Medicare and Medicaid Services, which oversees the health-care law. "The website performed optimally and consumers easily accessed enrollment tools to compare plans and prices."

 Acting Health and Human Services Secretary Eric Hargan said in a speech last week that the administration wants the sign-up period to be "as consumer friendly as possible."

 The administration cut the outreach budget by 90 percent and cut back on grants to outside groups, called navigators, that help people enroll. |||||
A summary of this is?

– Bucking expectations, ObamaCare is off to a record-breaking start. The Hill reports that around 200,000 signed up for health care coverage on the first day of this year's enrollment period, compared to 100,000 last year. Such early enthusiasm is good news for fans of ObamaCare, many of whom assumed enrollment would be down this year due to actions by the Trump administration, including slicing the advertising budget by 90% and cutting the length of the enrollment period by half. Still, despite the early high numbers, analysts say early enrollees tend to be renewing coverage, not getting it for the first time. Last week Standard & Poor's said enrollment could drop by as much as 1.6 million this year. With the government's advertising budget just $10 million, some insurance companies are spending their own money to spread the word about the enrollment period, Reuters reports. These companies are using advertising both to bring in the young, healthy customers whose coverage keeps premiums down and to clear up any confusion about the cessation of subsidies under Trump. The ObamaCare numbers come as reports have surfaced that the Trump administration is preparing an executive order that would effectively wipe out the mandate that most Americans have health insurance. The order would state that the administration will not collect the tax penalties from people who fail to get coverage, CNBC reports.