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Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity

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Abstract

Purpose

To explore norms of decision making regarding life-sustaining treatments (LSTs) at two academic medical centers (AMCs) that contribute to their opposite extremes of end-of-life ICU use.

Methods

We conducted a 4-week mixed methods case study at each AMC in 2008–2009 involving direct observation of patient care during rounds in the main medical ICU, semi-structured interviews with staff, patients, and families, and collection of artifacts (e.g., patient lists, standardized forms). We compared patterns of decision making regarding initiation, continuation, and withdrawal of LST using tests of proportions and grounded theory analysis of field note and interview transcripts.

Results

We observed 80 patients [26 (32.5 %) ≥65 years old] staffed by 4 attendings, and interviewed 23 staff and 3 patients/families at the low-intensity AMC (LI-AMC), and observed 73 patients [26 (35.6 %) ≥65 years old] staffed by 4 attending physicians and interviewed 26 staff and 4 patients/families at the high-intensity AMC (HI-AMC). LST initiation among patients over 65 was similar, except feeding tubes (0 % LI-AMC versus 31 % HI-AMC, p = 0.002). The LI-AMC was more likely to use a time-limited trial of LST, followed by withdrawal (27 vs. 8 %, p = 0.01) and to have a known outcome of death (31 vs. 4 %, p < 0.001). We identified qualitative differences in goals of LST, the determination of “dying,” concern about harms of commission versus omission, and physician self-efficacy for LST decision making.

Conclusions

Time-limited trials of LST at the LI-AMC and open-ended use of LST at the HI-AMC explain some of the AMCs’ nationally profiled differences in end-of-life ICU use.

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Acknowledgments

Study Advisory Committee: Derek C. Angus, Judith R. Lave, Mary Elizabeth Happ, Megan Crowley-Matoka, Jonathan Skinner, Denise Anthony, Denise Rousseau, Sharyn Sutton; Dartmouth Atlas: Elliott Fisher, Yunjie Song; Institutional contacts and investigators: Michael Gropper, J. Thomas Rosenthal, Rajan Saggar; Other intellectual contributions and research assistance: Margaret Crighton, Courtney Sperlazza, Elan Cohen. This work was supported by the National Institute for Nursing Research (R21NR010265).

Conflicts of interest

There are no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work.

Author information

Authors and Affiliations

  1. Center for Research on Health Care, University of Pittsburgh, 200 Meyran, Suite 200, Pittsburgh, PA, 15221, USA

    Amber E. Barnato, Keri L. Rodriguez, Susan L. Zickmund & Robert M. Arnold

  2. Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Amber E. Barnato, Keri L. Rodriguez, Susan L. Zickmund & Robert M. Arnold

  3. Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Amber E. Barnato

  4. Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA

    Judith A. Tate

  5. Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Keri L. Rodriguez & Susan L. Zickmund

  6. Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Robert M. Arnold

  7. UPMC Institute for Palliative and Supportive Care, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Robert M. Arnold

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  1. Amber E. Barnato
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Correspondence to Amber E. Barnato.

Additional information

This article is discussed in the editorial available at: doi:10.1007/s00134-012-2667-0.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

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Barnato, A.E., Tate, J.A., Rodriguez, K.L. et al. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med 38, 1886–1896 (2012). https://doi.org/10.1007/s00134-012-2661-6

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