Advance Care Planning Norms May Contribute to Hospital Variation in End-of-Life ICU Use

Abstract

Background. There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation. Methods. This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning. Results. Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a do-not-resuscitate order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient’s known metastatic gastric cancer in the context of norms of oncologists’ avoiding code status discussions. Conclusions: In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.