title: Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life--Updated.
abstract: BACKGROUND
  End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care.
  
  
  OBJECTIVE
  To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models.
  
  
  METHODS
  Ethnographic study of three critical care units.
  
  
  METHODS
  University hospitals in the United States and New Zealand.
  
  
  METHODS
  Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends.
  
  
  RESULTS
  Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families.
  
  
  CONCLUSIONS
  End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Joan
authors.initials: J
authors.lastname: Cassell
authors.forename: Timothy G
authors.initials: TG
authors.lastname: Buchman
authors.forename: Stephen
authors.initials: S
authors.lastname: Streat
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Stewart
mesh_terms: D000884:Anthropology, Cultural; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D003220:Conflict, Psychological; D003299:Cooperative Behavior; D003422:Critical Care / Q000941:ethics* / Q000458:organization & administration; D003431:Cross-Cultural Comparison; D003659:Decision Making, Organizational; D005190:Family / Q000523:psychology; D013502:General Surgery / Q000941:ethics* / Q000458:organization & administration; D015276:Health Care Rationing / Q000941:ethics / Q000458:organization & administration; D006785:Hospitals, University; D006801:Humans; D017146:Models, Organizational; D009520:New Zealand; D015279:Organizational Culture; D016134:Organizational Policy; D010686:Philosophy, Medical; D010819:Physician's Role; D011209:Power, Psychological; D011368:Professional-Family Relations; D011788:Quality of Life; D013727:Terminal Care / Q000941:ethics* / Q000458:organization & administration; D014481:United States