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    Original Investigation
    Critical Care Medicine
    December 11, 2019

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

    Author Affiliations
    • 1Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University, Chicago, Illinois
    • 2Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
    • 3Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
    • 4Department of Health Policy, Vanderbilt University, Nashville, Tennessee
    • 5Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
    • 6Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
    • 7College of Nursing, The Ohio State University, Columbus
    • 8Sutter Health, Sacramento, California
    • 9Society of Critical Care Medicine, Mount Prospect, Illinois
    • 10Division of Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee
    JAMA Netw Open. 2019;2(12):e1917344. doi:10.1001/jamanetworkopen.2019.17344
    Key Points español 中文 (chinese)

    Question  Do intensive care units in the United States provide high-quality end-of-life care?

    Findings  In this cohort study of 1536 decedents within a national quality improvement collaborative, end-of-life care delivery varied widely between intensive care units. There were 3 mutually exclusive unit-level patterns of end-of-life care delivery observed, which suggest meaningful differences in the experience of dying for patients cared for in higher-performing and lower-performing units.

    Meaning  To improve care for all patients who die in an intensive care unit, future research should target unit-level variation and investigate the latent characteristics of high-performing units that promote high-quality end-of-life care.

    Abstract

    Importance  Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death.

    Objective  To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States.

    Design, Setting, and Participants  This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019.

    Main Outcomes and Measures  Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU.

    Results  Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events.

    Conclusions and Relevance  In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.

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