Factors influencing the use of intensive procedures at the end of life.
OBJECTIVE
To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life.


METHODS
Retrospective cohort study.


METHODS
The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults.


METHODS
HRS decedents aged 66 and older (N = 3,069).


METHODS
Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life.


RESULTS
Approximately 18% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85-94 (vs 65-74, adjusted odds ratio (AOR) = 0.67, 95% confidence interval (CI) = 0.51-0.90), Alzheimer's disease (AOR = 0.71, 95% CI = 0.54-0.94), cancer (AOR = 0.60, 95% CI = 0.43-0.85), nursing home residence (AOR = 0.70, 95% CI = 0.50-0.97), and having an advance directive (AOR = 0.71, 95% CI = 0.57-0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95% CI = 1.48-3.13) and black race (AOR = 2.02, 95% CI = 1.52-2.69) each doubled one's odds of undergoing an intensive procedure.


CONCLUSIONS
Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Evan C
EC
Tschirhart
Qingling
Q
Du
Amy S
AS
Kelley
D016223:Advance Directives / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000401:mortality / Q000628:therapy; D002423:Cause of Death; D002908:Chronic Disease / Q000401:mortality* / Q000628:therapy*; D003422:Critical Care / Q000706:statistics & numerical data*; D005260:Female; D006707:Homes for the Aged / Q000706:statistics & numerical data; D006801:Humans; D008020:Life Support Care / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009369:Neoplasms / Q000401:mortality / Q000628:therapy; D009735:Nursing Homes / Q000706:statistics & numerical data; D016017:Odds Ratio; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data
Medicare; end-of-life decisions; intensive care; terminal care