title: Advance care planning norms may contribute to hospital variation in end-of-life ICU use: a simulation study.
abstract: There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation.
  
  
  
  This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning.
  
  
  
  Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a do-not-resuscitate order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient's known metastatic gastric cancer in the context of norms of oncologists' avoiding code status discussions.
  
  
  
  In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.
authors.affiliation: Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA (AEB, RMA).|Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, RMA)|Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh,
  PA (AEB)|The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, DM, DCA)
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.affiliation: The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, DM, DCA)
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California–San Francisco Medical Center, San Francisco, CA (RKL)
authors.forename: Rondall K
authors.initials: RK
authors.lastname: Lane
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA (YMH, DCA)
authors.forename: Yue Ming
authors.initials: YM
authors.lastname: Huang
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA (YMH, DCA)
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.affiliation: RAND Corporation, Pittsburgh, PA (CF)
authors.forename: Coreen
authors.initials: C
authors.lastname: Farris
authors.affiliation: Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA (AEB, RMA).|Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (AEB, RMA)|Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (RMA)
authors.forename: Robert M
authors.initials: RM
authors.lastname: Arnold
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration / Q000706:statistics & numerical data; D000328:Adult; D032722:Advance Care Planning / Q000706:statistics & numerical data*; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning / Q000458:organization & administration / Q000706:statistics & numerical data*; D016544:Patient Simulation; D010820:Physicians; D011379:Prognosis; D013727:Terminal Care / Q000458:organization & administration / Q000706:statistics & numerical data*
keywords: Medicare; cancer; heuristics; intensive care; national health policy; palliative care; physician decision making; qualitative research; simulation; terminal care; variation