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Med Decis Making. 2014 May;34(4):473-84. doi: 10.1177/0272989X14522099. Epub 2014 Mar 10.

Advance care planning norms may contribute to hospital variation in end-of-life ICU use: a simulation study.

Author information

1
Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA (AEB, RMA).
2
Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, RMA)
3
Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (AEB)
4
The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, DM, DCA)
5
Department of Anesthesia and Perioperative Care, University of California–San Francisco Medical Center, San Francisco, CA (RKL)
6
Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA (YMH, DCA)
7
RAND Corporation, Pittsburgh, PA (CF)
8
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (RMA)

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.

KEYWORDS:

Medicare; cancer; heuristics; intensive care; national health policy; palliative care; physician decision making; qualitative research; simulation; terminal care; variation

PMID:
24615275
PMCID:
PMC4026761
DOI:
10.1177/0272989X14522099
[Indexed for MEDLINE]
Free PMC Article

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