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Observational Study
. 2019 Dec 2;2(12):e1917344.
doi: 10.1001/jamanetworkopen.2019.17344.

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

Jacqueline M Kruser  1   2 , David A Aaby  3 , David G Stevenson  4   5 , Brenda T Pun  6 , Michele C Balas  7 , Mary Ann Barnes-Daly  8 , Lori Harmon  9 , E Wesley Ely  5   6   10
Affiliations
Observational Study

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

Jacqueline M Kruser et al. JAMA Netw Open. .

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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Pun reported receiving personal fees for serving as a subject matter expert for the Society of Critical Care Medicine during the conduct of the study; receiving personal fees for teaching from the American Association of Critical-Care Nurses outside the submitted work; and receiving honoraria from the Michigan Hospital Association outside the submitted work. Dr Balas reported receiving honoraria from the Society of Critical Care Medicine during the conduct of the study; receiving grants from National Institutes of Health and the American Association of Critical-Care Nurses outside the submitted work; and receiving honoraria from the Michigan Hospital Association and Select Medical outside the submitted work. Dr Barnes-Daly reported being on a speakers bureau for Cheetah Medical. Dr Ely reported receiving personal fees from the Gordon and Betty Moore Foundation during the conduct of the study; receiving personal fees for serving as an independent lecturer for Pfizer and Orion Corporation outside the submitted work; and having an ongoing research relationship with Masimo outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Variation in End-of-Life Events Among Intensive Care Units (ICUs) in the United States
Each circle represents a single ICU, and the y-axis value represents the percentage of decedents in that unit who experienced the event. Units are ranked from 1, representing the lowest end-of-life event frequency, to 68, representing the highest event frequency, along the x-axis. The size of each circle is proportional to the total number of decedents in that unit. The dotted lines indicate the median event rate among all units. CPR indicates cardiopulmonary resuscitation.
Figure 2.
Figure 2.. Unit-Level Patterns of End-of-Life (EOL) Care Delivery
Cluster analysis revealed 3 mutually exclusive, unit-level patterns of end-of-life care delivery. Of 63 intensive care units (ICUs) in this analysis, 14 (22.2%) belonged to cluster 1, which had the lowest rate of extubation before death and the lowest rate of cardiopulmonary resuscitation (CPR) avoidance but the highest pain-free rate. The 25 units (39.7%) belonging to cluster 2 had the lowest delirium-free rate but high rates of all other EOL events. The 24 units (38.1%) belonging to cluster 3 had consistently high rates across all 5 EOL events. The upper and lower bounds of the boxes represent the 75th and 25th percentiles, respectively. The midbox horizontal line represents the median. The maximum and minimum observations are indicated by the vertical whiskers, and outliers are indicated by circles.
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