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Original Research: Critical Care |

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICUICU Physician Staffing Impact on End-of-Life Care

Michael E. Wilson, MD; Ramez Samirat, MD; Murat Yilmaz, MD; Ognjen Gajic, MD, FCCP; Vivek N. Iyer, MD, MPH
Author and Funding Information

From the Department of Internal Medicine (Dr Wilson), Divisions of Pulmonary and Critical Care Medicine (Drs Gajic and Iyer), Department of Internal Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine (Dr Samirat), University of Miami Jackson Memorial Hospital, Miami, FL; and the Department of Anesthesiology and Intensive Care (Dr Yilmaz), Akdeniz University, Antalya, Turkey.

Correspondence to: Vivek N. Iyer, MD, MPH, Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: iyer.vivek@mayo.edu


Funding/Support: Financial support for this study was provided by the Mayo Clinic and Mayo Foundation.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(3):656-663. doi:10.1378/chest.12-1173
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Background:  A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making.

Methods:  A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record.

Results:  The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death (P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days (P = .09), time to decision to limit any life support was shortened by 1 day (P = .08), time to death was shortened by 2 days (P = .08), and intubations against patient wishes decreased (from three to none; P = .12).

Conclusions:  The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.


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