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Original Research: Critical Care |

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery PhysiciansPalliative Care Differences by Physician Specialty

Erin K. Kross, MD; Ruth A. Engelberg, PhD; Lois Downey, MA; Joseph Cuschieri, MD; Matthew R. Hallman, MD; W. T. Longstreth, Jr, MD, MPH; David L. Tirschwell, MD; J. Randall Curtis, MD, MPH, FCCP
Author and Funding Information

From the Division of Pulmonary & Critical Care Medicine, Department of Medicine (Drs Kross, Engelberg, and Curtis and Ms Downey), Department of Surgery (Dr Cuschieri), Department of Anesthesiology & Pain Medicine (Dr Hallman), and Department of Neurology (Drs Longstreth and Tirschwell), University of Washington, Harborview Medical Center, Seattle, WA.

Correspondence to: Erin K. Kross, MD, Division of Pulmonary & Critical Care Medicine, Harborview Medical Center, 325 Ninth Ave, Box 359762, Seattle, WA 98104; e-mail: ekross@uw.edu


Funding/Support: This study was supported by the National Institute of Nursing Research [R01NR05226 to Dr Curtis] and the National Heart, Lung and Blood Institute [K23HL098745 to Dr Kross].

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


Chest. 2014;145(2):313-321. doi:10.1378/chest.13-1351
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Background:  Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of critical care by different specialties.

Methods:  We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics.

Results:  Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine (P < .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians (P < .05). Chart documentation of indicators of palliative care differed by attending specialty.

Conclusions:  Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These findings may provide insights into potential ways to improve the quality of dying for all patients.

Trial registry:  ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov


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