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Hospital Variation and Temporal Trends in Palliative and End-of-Life Care in the ICU*

DeCato, Thomas W. MD1; Engelberg, Ruth A. PhD2; Downey, Lois MA2; Nielsen, Elizabeth L. MPH2; Treece, Patsy D. RN, MN2; Back, Anthony L. MD3; Shannon, Sarah E. RN, PhD4; Kross, Erin K. MD2; Curtis, J. Randall MD, MPH2

doi: 10.1097/CCM.0b013e318287f289
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Objectives: Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented.

Design/Setting: Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008.

Measurements: We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics.

Main Results: Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU.

Conclusions: We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.

1 Department of Medicine, University of Washington, Seattle, WA.

2 Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.

3 Department of Medical Oncology, University of Washington and Seattle Cancer Care Alliance, Seattle, WA.

4 Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA.

*See also p. 1568.

Supported, in part, by the National Institute of Nursing Research (R01 NR005226) and the Robert Wood Johnson Foundation.

Registered at ClinicalTrials.gov: NCT00685893.

Drs. Engelberg, Downey, and Treece are employed by the University of Washington. Dr. Downey is employed by the Lifeling Aids Alliance, Consejo Counseling Services, and Prevention Research Institute (PrimeFor Life.org). Dr. Shannon is employed by the University of Washington Medical Center.

Dr. Shannon consults for the Seattle University School of Nursing. Dr. Shannon lectured for various local health care institutions and professional organizations.

Drs. Nielsen, Treece, Back, Shannon, and Curtis received grant support from the National Institutes of Health. Dr. Engelberg received grant support from the National Palliative Care Research Center, NIH/NHLBI, and the Robert Wood Johnson Foundation. Dr. Nielsen received grant support from NPCRC.Dr. Downey received grant support from the RWJ Foundation, NIH/NINR, NIH/NHLBI, NIH/NCI, and NIH/NCCAM. Dr. Kross received grant support from NIH (NIH-K23 Career Development Award).

Dr. DeCato has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: jrc@u.washington.edu

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins