title: Hospital variation and temporal trends in palliative and end-of-life care in the ICU.
abstract: OBJECTIVE
  Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented.
  
  
  METHODS
  Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008.
  
  
  METHODS
  We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics.
  
  
  RESULTS
  Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU.
  
  
  CONCLUSIONS
  We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.
authors.affiliation: Department of Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Thomas W
authors.initials: TW
authors.lastname: DeCato
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg
authors.forename: Lois
authors.initials: L
authors.lastname: Downey
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Nielsen
authors.forename: Patsy D
authors.initials: PD
authors.lastname: Treece
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Back
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Shannon
authors.forename: Erin K
authors.initials: EK
authors.lastname: Kross
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003258:Consumer Behavior; D005190:Family; D005260:Female; D006739:Hospital Administration / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000639:trends; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital / Q000458:organization & administration / Q000639:trends; D010166:Palliative Care / Q000458:organization & administration* / Q000639:trends; D011787:Quality of Health Care / Q000458:organization & administration / Q000639:trends; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D012947:Social Work / Q000458:organization & administration / Q000639:trends; D013727:Terminal Care / Q000458:organization & administration* / Q000639:trends; D013997:Time Factors; D014861:Washington