PURPOSE: Over 500,000 deaths occur around an intensive care admission requiring the integration of palliative and end of life care in the ICU. (1) Furthermore, there is significant variation in ICU care at the end of life among hospitals, suggesting policies to minimize variation.(2,3) Meanwhile, several interventions involving system change, including education, bedside tools, palliative care consultation, have been shown to reduce potentially non-beneficial care in the ICU. (4-7) The objective of this study is to evaluate the association of modifiable factors within the training program, education and bedside tools, with intensive care use in the last 6 months of life.(ICUD6M)
METHODS: We performed a retrospective cohort study linking data from the ACCP PEOLC Network program directors’ survey and medicare data, that included a total of 71 eligible programs and their 78 affiliated hospitals. The quality of education was identified by the program director’s perception of the quality of their palliative care education on a scale from 1-5. The number of evidence-based tools was identified by the availability of the following: 1) family booklet, 2) communication prompt card, 3) withdrawal of life support protocol, and 4) a bereavement brochure. Data for the dependent variable, hospital specific averages for ICUD6M in 2005, was identified from the Dartmouth Atlas(8). Multivariate regression analysis was used.
RESULTS: In our cohort,the overall quality of palliative care education, on a scale from 1-5, was associated with 0.47 fewer ICU days per integer on the scale (p=0.06). Furthermore, the availability of evidence-based bedside tools was associated with 0.39 fewer ICU days per tool (p=0.008).
CONCLUSIONS: The quality of palliative care education and the number of related evidence-based bedside tools are associated with decreased intensive care use at the end of life, in a near independent manner.
CLINICAL IMPLICATIONS: System support, targeting both education and facilitation of care at the bedside, may have widespread impact on the use of ICU care at the end of life in teaching institutions.
DISCLOSURE: The following authors have nothing to disclose: Howard Saft, Paul Richman, Andrew Berman, Dee Ford, Daniel Ray, Paul Selecky
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