The wide-ranging report from the Dartmouth Atlas Project uses Medicare claims data to examine aging Americans’ health care. Among other things, it identified five areas where too many older people receive treatments that don’t meet established guidelines or, often, their own goals and preferences.

Two of the five involve preventive steps that may not benefit seniors: screenings for breast cancer and prostate cancer. The other three address care at the end of life: late referral to hospice care, time in intensive care units and the placement of feeding tubes in people with dementia.

These shortcomings highlight the need for better communication and shared decision-making among patients, their families and their medical providers.

People judge the harms and benefits of treatments differently, and “that’s where the shared decision-making comes in,” said one of the report’s authors, Julie Bynum, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.

Mammograms to detect breast cancer and blood tests to check for prostate cancer are simple procedures. But these screenings can set off a cascade of further testing and treatment when the results are worrisome. Those follow-up efforts can harm older patients, who may be fragile or have multiple medical conditions.

In addition, older people may well die from something else before a recently revealed cancer progresses, said Richard Wender, chief cancer control officer at the American Cancer Society.

“The single hardest concept for the public to understand is the natural history of finding a cancer through a screening process,” Wender said. “Many people have the sense that had it not been found, that cancer would have threatened their life within a couple of years or maybe even a couple of months.”

Experts have cautioned older patients about both mammograms and prostate tests. The U.S. Preventive Services Task Force, an independent panel of physicians, has concluded that PSA blood tests aren’t beneficial at any age and that there’s not enough evidence to know whether the benefit of breast cancer screening after a woman reaches age 75 outweighs the risks.

Still, the Dartmouth Atlas analysis found that 20 percent of male Medicare beneficiaries age 75 and older got a PSA test to screen for prostate cancer in 2012, and 24 percent of female beneficiaries that age had a mammogram to screen for breast cancer.

Guidelines aside, clinicians and their patients need to discuss the pros and cons of testing and make a decision based on the patient’s values and preferences, experts say.

For example, a 75-year-old woman who is willing to accept that she might die of breast cancer within 10 years but wants to avoid the anxiety and harms of treatment might choose not to be tested.

“I ask people, ‘Do you think you’re going to be around in 10 years? Help me decide whether to order a mammogram,'” said Bynum, whose work focuses on geriatrics.

As people near the end of their lives, it’s especially important for patients and their family members to discuss their goals and wishes with clinicians. Patients often want to be kept comfortable rather than undergo medical interventions, but physicians and nurses are still trained to do everything possible to prevent death, said Diane Meier, the director of the Center to Advance Palliative Care and a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York.

The three end-of-life criteria cited by the Dartmouth researchers are areas that geriatrics experts agree are critical, Bynum said, but it has proved difficult to get providers, health systems and the general public to address them. Late referral to hospice and spending time in a hospital intensive care unit, the report found, can adversely affect terminal patients’ health, result in higher costs and run counter to their hope for a peaceful death. For people with advanced dementia, the insertion of feeding tubes can lead to complications.

Federal data show that less than half of Medicare beneficiaries who die use hospice services, but the Dartmouth study found that even those who did turn to hospice often did it late. Seventeen percent of Medicare beneficiaries who died in 2012 weren’t enrolled in hospice until the last three days of life. Medicare will approve hospice benefits, which generally include comfort care rather than curative treatment, when a physician certifies that someone is expected to live for no more than six months.

The study also found that people spent an average of nearly four days in intensive care during the last six months of life, a figure that is trending upward.

Finally, even though it doesn’t prolong their lives to place feeding tubes in patients with dementia, who naturally lose interest in food and their ability to swallow in the final stages of the disease, 6 percent of Medicare beneficiaries with dementia received them in their last six months of life in 2012.

Communication is key, but the skills that are needed to counsel patients aren’t being taught, Meier said.

“If you unleash an oncologist who does not know how to say, ‘Your cancer has progressed,’ but they know how to say, ‘I know what we can try,’ that’s why people end up in the ICU and with feeding tubes” at the end of life, she said. “It’s easier than having a difficult conversation.”

This column is produced through a collaboration between The Post and Kaiser Health News.