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End-of-life care for the critically ill: A national intensive care unit survey*

Nelson, Judith E. MD, JD; Angus, Derek C. MD, ChB, MPH; Weissfeld, Lisa A. PhD; Puntillo, Kathleen A. RN, DNSc, FAAN; Danis, Marion MD; Deal, David BS; Levy, Mitchell M. MD, FCCM; Cook, Deborah J. MD, MSc (Epid), FRCPC

doi: 10.1097/01.CCM.0000239233.63425.1D
Continuing Medical Education Article

Objective: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care.

Design: Self-administered mail survey.

Setting: Six hundred intensive care units.

Participants: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States.

Interventions: Mail survey.

Measurements and Main Results: We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians’ time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available.

Conclusions: Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.

LEARNING OBJECTIVES On completion of this article, the reader should be able to:

  1. Describe barriers to improved end-of-life care in the intensive care unit.
  2. List strategies that are likely to improve end-of-life care.
  3. Use this information in the clinical setting.

Describe barriers to improved end-of-life care in the intensive care unit.List strategies that are likely to improve end-of-life care.Use this information in the clinical setting. All authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity.

Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.

Visit the Critical Care Medicine Web site ( for information on obtaining continuing medical education credit.

Associate Professor in Medicine, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY (JEN); Professor and Vice Chair, Director, CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine (DCA), Professor of Biostatistics, University of Pittsburgh (LAW), Pittsburgh, PA; Professor of Nursing, University of California, San Francisco, San Francisco, CA (KAP); Chief, Bioethics Consultation Service, Clinical Center, National Institutes of Health, Bethesda, MD (MD); Survey Director, Abt Associates, Cambridge MA (DD); Director, Critical Care Services, Medical Director, MICU, Rhode Island Hospital, Professor of Medicine, Brown Medical School, Providence, RI (MML); and Professor of Medicine & Biostatistics & Clinical Epidemiology, Academic Chair, Critical Care, Canada Research Chair, Department of Clinical Epidemiology, McMaster University, Hamilton, Ontario, Canada (DJC).

Supported, in part, by the Robert Wood Johnson Foundation. Dr. Nelson is the recipient of an Independent Scientist Award (K02 AG024476) from the National Institute on Aging. At the time of this work, Drs. Nelson and Puntillo were Faculty Scholars of the Project on Death in America. Dr. Cook is a Research Chair of the Canadian Institutes of Health Research.

Address requests for reprints to: Judith E. Nelson, MD, JD, Box 1232, Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029. E-mail:

© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins