title: Physician staffing models impact the timing of decisions to limit life support in the ICU.
abstract: 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.
authors.affiliation: Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Wilson
authors.affiliation: Department of Internal Medicine, University of Miami Jackson Memorial Hospital, Miami, FL.
authors.forename: Ramez
authors.initials: R
authors.lastname: Samirat
authors.affiliation: Department of Anesthesiology and Intensive Care, Akdeniz University, Antalya, Turkey.
authors.forename: Murat
authors.initials: M
authors.lastname: Yilmaz
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Ognjen
authors.initials: O
authors.lastname: Gajic
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN. Electronic address: iyer.vivek@mayo.edu.
authors.forename: Vivek N
authors.initials: VN
authors.lastname: Iyer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D006784:Hospitals, Teaching / Q000458:organization & administration; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D008020:Life Support Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D008297:Male; D008505:Medical Staff, Hospital / Q000458:organization & administration*; D008875:Middle Aged; D008910:Minnesota; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D012121:Respiration, Artificial; D016414:Resuscitation Orders; D012189:Retrospective Studies; D013727:Terminal Care / Q000592:standards; D013997:Time Factors; D000078329:Workforce