Differences in end-of-life care in the icu across medicine, surgery, neurology and neurosurgery services

Abstract

Introduction: We examined whether ICU discharge service was associated with quality end-of-life care as assessed by family and nurse ratings of the quality of dying, family satisfaction with care, and chart documentation of palliative care. Methods: We conducted a secondary analysis of data from a clustered randomized trial of 14 hospitals in Washington State. Eligible patients died in the ICU or within 30 hours of transfer from the ICU and were categorized by discharge service (medicine, surgery, neurology or neurosurgery). Families completed post-death surveys rating satisfaction with care, and families and nurses rated quality of dying. We also abstracted medical records to assess documentation of indicators of palliative care. Associations between discharge service and family- or nurse-assessed outcomes were tested with multi-predictor regression models using restricted maximum likelihood estimates. Nurse outcomes were clustered under the nurse. Associations between discharge service and documentation of palliative care indicators were tested with multi-predictor logistic regression or Cox models. All models were adjusted for hospital site and patient characteristics, and models assessing family- or nurse-assessed outcomes for family or nurse characteristics, respectively. Results: 3124 patients died during the study period. The majority of patients were white (79%), male (58%), had a mean age of 69 years and were discharged from medicine (78%), with fewer from surgery (12%), neurology (3%) and neurosurgery (6%). Family satisfaction with care did not vary by service. Families and nurses of patients discharged from neurology and neurosurgery services rated quality of dying higher than families and nurses of patients discharged from a medicine service (p<0.001, Table 1). Indicators of palliative care documented in the medical record differed by service (Table 2). As compared to medicine patients, other patients had fewer palliative care consults. Neurology and neurosurgery patients had more DNR orders, less CPR, more family conferences, and more prognostic discussions. Neurology patients had shorter ICU stays and shorter time to withdrawal of mechanical ventilation. Surgical patients had fewer DNR orders, less often had life-sustaining therapies withdrawn, had more CPR, longer ICU stays and more time to withdrawal of mechanical ventilation (all p<0.01). Conclusions: Patients discharged from neurology and neurosurgical services have higher family and nurse ratings of quality of dying than patients on medicine services and a different pattern of indicators of palliative care. Patients from surgical services had fewer documented indicators of palliative care. These findings may provide insights to ways to improve the quality of dying for all patients. (Table Presented).