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Am J Hosp Palliat Care. 2018 Mar;35(3):377-383. doi: 10.1177/1049909117710633. Epub 2017 Jun 2.

Occupational Variation in End-of-Life Care Intensity.

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1 Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
2 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
3 Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
4 Harvard Medical School, Boston, MA, USA.
5 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
6 Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.
7 School of Nursing and Health Science, University of Massachusetts Boston, Boston, MA, USA.
8 Center for Research on the End-of-Life Care, Weill Cornell Medicine, New York, NY, USA.
9 Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.



End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care.


We investigated occupation as a source of variation in EOL care intensity.


Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death.


Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance.


Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.


Medicare; end-of-life care; occupation; variation

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