End-of-life care for the critically ill: A national intensive care unit survey.
OBJECTIVE
One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care.


METHODS
Self-administered mail survey.


METHODS
Six hundred intensive care units.


METHODS
A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States.


METHODS
Mail survey.


RESULTS
We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available.


CONCLUSIONS
Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.
Nelson
Judith E
JE
Department of Medicine, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY 10029, USA. judith.nelson@mountsinai.org
Angus
Derek C
DC
Weissfeld
Lisa A
LA
Puntillo
Kathleen A
KA
Danis
Marion
M
Deal
David
D
Levy
Mitchell M
MM
Cook
Deborah J
DJ
D001291:Attitude of Health Personnel; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009718:Nurse Administrators / Q000523:psychology; D010166:Palliative Care / Q000379:methods* / Q000458:organization & administration; D008486:Physician Executives / Q000523:psychology; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care; D013727:Terminal Care / Q000379:methods* / Q000458:organization & administration; D014481:United States