Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States

Kruser, Jacqueline M.; Aaby, David; Stevenson, David G.; Pun, Brenda T.; Balas, Michele C.; Barnes‐Daly, Mary Ann; Harmon, Lori; Ely, E. Wesley

doi:10.1001/jamanetworkopen.2019.17344

Cited by 35 publications

(25 citation statements)

References 56 publications

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“…This approach to adjudicating the primary cause of death had excellent interrater reliability in previous studies ( 5 ), and there was full agreement between our abstractors on an initial set of 10 charts reviewed independently. Data on coinfection, goals-of-care discussions, advanced directives, spiritual support, respiratory support, and family presence at the time of death were also collected ( 6 ). The study definitions are presented in Table 1 .…”

Section: Methodsmentioning

confidence: 99%

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Causes and Circumstances of Death among Patients Hospitalized with COVID-19: A Retrospective Cohort Study

et al. 2021

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Section: Methodsmentioning

confidence: 99%

“… Definition of abbreviations : COVID-19 = coronavirus disease; PCR = polymerase chain reaction. * Adapted from or as defined in Kruser and colleagues ( 6 ). † Adapted from or as defined in Ketcham and colleagues ( 5 ).…”

Section: Methodsmentioning

confidence: 99%

Causes and Circumstances of Death among Patients Hospitalized with COVID-19: A Retrospective Cohort Study

et al. 2021

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“…Being in a critical care unit at the end of life is associated with a more medicalised death, greater focus on active treatments and a high level of medical interventions. (1,2) Conversely, families reported greater satisfaction around quality of care and dignity when death occurred in hospital ward settings. (3) While good quality end-of-life care is possible in critical care even without formal palliative care input, it remains variable.…”

Section: Introductionmentioning

confidence: 99%

“…(3) While good quality end-of-life care is possible in critical care even without formal palliative care input, it remains variable. (2,4) Moreover, the opportunities for timely end-oflife care provision are reduced by virtue of the clinical characteristics of patients who die in critical care, particularly when death is unexpected. (5) Hospice care centres on providing end-of-life care that is consistent with the values and priorities of patients and their families.…”

Section: Introductionmentioning

confidence: 99%

Deaths in critical care and hospice—prevalence, trends, influences: a national decedent cohort study

Mayes

McLachlan

Carduff

et al. 2021

BMJ Support Palliat Care

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ObjectivesEnd-of-life and bereavement care support services differ in critical care and inpatient hospice settings. There are limited population-level data comparing deaths in these two locations. We aimed to compare the characteristics of people who die in critical care units and in hospices, identify factors associated with place of death and report 12-year trends in Scotland.MethodsWe undertook a cohort study of decedents aged ≥16 years in Scotland (2005–2017). Location of death was identified from linkage to the Scottish Intensive Care Society Audit Group database and National Records of Scotland Death Records. We developed a multinomial logistic regression model to identify factors independently associated with location of death.ResultsThere were 710 829 deaths in Scotland, of which 36 316 (5.1%) occurred in critical care units and 42 988 (6.1%) in hospices. As a proportion of acute hospital deaths, critical care deaths increased from 8.0% to 11.2%. Approximately one in eight deaths in those aged under 40 years occurred in critical care. Factors independently associated with hospice death included living in less deprived areas, cancer as the cause of death and presence of comorbidities. In contrast, liver disease and accidents as the cause of death and absence of comorbidities were associated with death in critical care.ConclusionsSimilar proportions of deaths in Scotland occur in critical care units and hospices. Given the younger age profile and unexpected nature of deaths occurring in critical care units, there is a need for a specific focus on end-of-life and bereavement support services in critical care units.

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“…When making a DFLST, physicians are greatly influenced by their personal characteristics including religion and culture [7,8], which results in considerable variability in their decisions [7,9]. This variability is constant within the same specialty or structure [10][11][12][13][14]. Patients want physicians to follow their wishes [15], but most ICU patients are not able to properly communicate these wishes because they lack decision-making capacity.…”

Section: Introductionmentioning

confidence: 99%

Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

et al. 2020

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Background There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients’ characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. Conclusions ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist’s decision took priority. Further research is needed to improve the matching of the physicians’ decision with the patient’s wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530.

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Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States

Cited by 35 publications

References 56 publications

Causes and Circumstances of Death among Patients Hospitalized with COVID-19: A Retrospective Cohort Study

Causes and Circumstances of Death among Patients Hospitalized with COVID-19: A Retrospective Cohort Study

Deaths in critical care and hospice—prevalence, trends, influences: a national decedent cohort study

Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment

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