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Original Research: Critical Care |

End-of-Life Expenditure in the ICU and Perceived Quality of DyingQuality of Dying, Satisfaction With Care and Costs

Nita Khandelwal, MD; Ruth A. Engelberg, PhD; David C. Benkeser, MPH; Norma B. Coe, PhD; J. Randall Curtis, MD, MPH
Author and Funding Information

From the Department of Anesthesiology and Pain Medicine (Dr Khandelwal) and the Division of Pulmonary and Critical Care Medicine (Drs Engelberg and Curtis), Harborview Medical Center, the Department of Medicine (Drs Engelberg and Curtis), the Department of Biostatistics (Mr Benkeser), and the Department of Health Services (Dr Coe), University of Washington, Seattle, WA.

CORRESPONDENCE TO: Nita Khandelwal, MD, Department of Anesthesiology and Pain Medicine, Harborview Medical Center, PO Box 359724, Seattle, WA 98104; e-mail: khandel@uw.edu


FUNDING/SUPPORT: This work was supported by the National Institute of Nursing Research [Grant R01NR005226] and the National Institute of General Medical Sciences [Grant 5T32GM086270].

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


Chest. 2014;146(6):1594-1603. doi:10.1378/chest.14-0182
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OBJECTIVE:  Although end-of-life care in the ICU accounts for a large proportion of health-care costs, few studies have examined the association between costs and satisfaction with care. The objective of this study was to investigate the association of ICU costs with family- and nurse-assessed quality of dying and family satisfaction.

METHODS:  This was an observational study surveying families and nurses for patients who died in the ICU or within 30 h of transfer from the ICU. A total of 607 patients from two Seattle hospitals were included in the study. Survey data were linked with administrative records to obtain ICU and hospital costs. Regression analyses assessed the association between costs and outcomes assessing satisfaction with care: nurse- and family-assessed Quality of Death and Dying (QODD-1) and Family Satisfaction in the ICU (FS-ICU).

RESULTS:  For family-reported outcomes, patient insurance status was an important modifier of results. For underinsured patients, higher daily ICU costs were significantly associated with higher FS-ICU and QODD-1 (P < .01 and P = .01, respectively); this association was absent for privately insured or Medicare patients (P = .50 and P = .85, QODD-1 and FS-ICU, respectively). However, higher nurse-assessed QODD-1 was significantly associated with lower average daily ICU cost and total hospital cost (P < .01 and P = .05, respectively).

CONCLUSIONS:  Family-rated satisfaction with care and quality of dying varied depending on insurance status, with underinsured families rating satisfaction with care and quality of dying higher when average daily ICU costs were higher. However, patients with higher costs were assessed by nurses as having a poorer quality of dying. These findings highlight important differences between family and clinician perspectives and the important role of insurance status.

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