Joshua A Rolnick1,2,3,4, Mary Ersek1,4,5, Melissa W Wachterman6,7,8, Scott D Halpern2,9. 1. Division of General Internal Medicine. 2. Palliative and Advanced Illness Research Center, and. 3. National Clinician Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania. 4. Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania. 5. University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. 6. Veterans Affairs Boston Healthcare System, Boston, Massachusetts. 7. Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and. 8. Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts. 9. Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, and.
Abstract
Rationale: Admissions to ICUs are common during terminal hospitalizations, but little is known about how ICU care affects the end-of-life experience for patients dying in hospitals and their families. Objectives: We measured the association between ICU care during terminal hospitalization and family ratings of end-of-life care for patients who died in 106 Veterans Affairs hospitals from 2010 to 2016. Methods: Patients were divided into four categories: no-ICU care, ICU-only care, mixed care (died outside ICU), and mixed care (died in ICU). Multivariable linear probability models were adjusted for patient and hospital characteristics. Patients receiving mixed care were also analyzed based on percentage of time in ICU.Measurements and Main Results: Of 57,550 decedents, 28,062 (48.8%) had a survey completed by a family member or close contact. In adjusted models, ICU-only care was associated with more frequent optimal ratings than no-ICU care, including overall excellent care (56.6% vs. 48.1%; P < 0.001), care consistent with preferences (78.7% vs. 72.4%; P < 0.001), and having pain controlled (51.3% vs. 46.7%; P < 0.001). Among patients with mixed care, increasing ICU time was associated with higher ratings on these same measures (all P < 0.001 for comparisons of those spending >75% time in ICU vs. ≤25% time).Conclusions: Among hospital decedents, ICU care was associated with higher family ratings of quality of end-of-life care than ward care. Reducing ICU use among hospital decedents may not improve end-of-life quality, and efforts to understand how ICU care improves end-of-life quality could help provide better care outside ICUs.
Rationale: Admissions to ICUs are common during terminal hospitalizations, but little is known about how ICU care affects the end-of-life experience for patients dying in hospitals and their families. Objectives: We measured the association between ICU care during terminal hospitalization and family ratings of end-of-life care for patients who died in 106 Veterans Affairs hospitals from 2010 to 2016. Methods:Patients were divided into four categories: no-ICU care, ICU-only care, mixed care (died outside ICU), and mixed care (died in ICU). Multivariable linear probability models were adjusted for patient and hospital characteristics. Patients receiving mixed care were also analyzed based on percentage of time in ICU.Measurements and Main Results: Of 57,550 decedents, 28,062 (48.8%) had a survey completed by a family member or close contact. In adjusted models, ICU-only care was associated with more frequent optimal ratings than no-ICU care, including overall excellent care (56.6% vs. 48.1%; P < 0.001), care consistent with preferences (78.7% vs. 72.4%; P < 0.001), and having pain controlled (51.3% vs. 46.7%; P < 0.001). Among patients with mixed care, increasing ICU time was associated with higher ratings on these same measures (all P < 0.001 for comparisons of those spending >75% time in ICU vs. ≤25% time).Conclusions: Among hospital decedents, ICU care was associated with higher family ratings of quality of end-of-life care than ward care. Reducing ICU use among hospital decedents may not improve end-of-life quality, and efforts to understand how ICU care improves end-of-life quality could help provide better care outside ICUs.
Entities:
Keywords:
health services research; palliative care; terminal care
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