Hospital variation and temporal trends in palliative and end-of-life care in the ICU

Abstract

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.

Trial registration: ClinicalTrials.gov NCT00685893.

Figure 1

Variability in chart-based outcomes among hospitals. This figure shows the performance of each hospital on four of the chart-based indicators of palliative care (two covering the last 24 hr of life: no cardiopulmonary resuscitation (CPR), pain assessments; and two covering the first 72 hr in the ICU: family conferences and prognostic discussions). For the purposes of illustration, the hospitals were divided into those with a smaller number of deaths (A; n = 7) and those with a larger number of deaths (B; n = 6). Each hospital is represented by a different line showing that hospitals vary in their relative position compared to other hospitals.

Figure 2

Outcome measures by hospital over time. This figure shows the change in the expected percentage of pain assessments in the last 24 hr of life (A) and family conferences in the first 72 hr in the ICU (B) over time for each individual hospital and for the total sample average. On average, pain assessments significantly increased over the study period (p < 0.001), while family conferences significantly decreased (p < 0.001). The within-hospital lines are adjusted for patient characteristics; the summary line (average [AVG]) is adjusted for patient characteristics and for hospital.