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To better understand the quality of end-of-life care inside and outside the ICU, Penn Medicine researchers analyzed patient and hospitalization characteristics from VA records and results from the Bereaved Family Survey, which are distributed to family members or close contacts of every veteran who dies in a VA acute care hospital or other VA institutional setting.
The study found that "ICU-only care" was associated with more frequent optimal ratings than "no ICU care," including overall excellent care (56.6 percent vs. 48.1 percent), care consistent with preferences (78.7 percent vs. 72.4 percent), and having pain controlled (51.3 percent vs. 46.7 percent).
Among patients with mixed care, increasing ICU time was associated with higher ratings on these same measures.
"Instead of just looking at people who got all of their care in the ICU and people who did not, we looked at all people in the hospital," Halpern said. "That actually provides the most compelling evidence that ICU care is associated with better end-of-life quality because we found that the greater the proportion of time spent in the ICU, the higher the quality of end-of-life care. It was a classic 'dose-response' relationship."
The higher ratings may be explained by the more favorable staffing ratios in the ICU and other features that can improve symptom management and other facets of care. ICUs have been the focus of significant research and guidelines on end-of-life care, so greater experience among clinicians and nurses may translate into improved communication and symptom management. And family members of patients receiving ICU care may take solace in knowing that all reasonable efforts to extend life were attempted - which may affect their ratings.
"The implication is that we should work to improve end-of-life care in acute care settings like hospital wards. And because moving people from ICUs to wards may not be a good strategy to improve their end-of-life experience, we need to focus instead on getting people out the hospital entirely for end of life care when feasible," said first author Joshua A. Rolnick, MD, a physician in Penn's division of General Internal Medicine and at the Philadelphia VA Medical Center.
A noteworthy secondary finding was the high rate of uncontrolled pain among patients: more than 50 percent. This finding is consistent with prior work suggesting high unmet needs for symptom management near the end of life that deserves further study and attention.
According to the researchers, further studies are warranted to not only better understand how factors in ICU may improve end-of-life care outside the ICU in the hospital, but also assisted-care settings, including home hospice care, and to help reduce overall hospitalizations. Source:
University of Pennsylvania School of Medicine Journal reference:
Rolnick, J. A., et al. (2020) The Quality of End-of-Life Care Among Intensive Care Unit Versus Ward Decedents. American Journal of Respiratory and Critical Care Medicine . doi.org/10.1164/rccm.201907-1423OC .
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