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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

Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA (AEB, RMA).
Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, RMA)
Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (AEB)
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)
Department of Anesthesia and Perioperative Care, University of California–San Francisco Medical Center, San Francisco, CA (RKL)
Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA (YMH, DCA)
RAND Corporation, Pittsburgh, PA (CF)
Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (RMA)



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.


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.


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.


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.


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

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