title: End-of-life expenditure in the ICU and perceived quality of dying.
abstract: OBJECTIVE
  Although end-of-life care in the ICU accounts for a large proportion of health-care costs, few studies have examined the association between costs and satisfaction with care. The objective of this study was to investigate the association of ICU costs with family- and nurse-assessed quality of dying and family satisfaction.
  
  
  METHODS
  This was an observational study surveying families and nurses for patients who died in the ICU or within 30 h of transfer from the ICU. A total of 607 patients from two Seattle hospitals were included in the study. Survey data were linked with administrative records to obtain ICU and hospital costs. Regression analyses assessed the association between costs and outcomes assessing satisfaction with care: nurse- and family-assessed Quality of Death and Dying (QODD-1) and Family Satisfaction in the ICU (FS-ICU).
  
  
  RESULTS
  For family-reported outcomes, patient insurance status was an important modifier of results. For underinsured patients, higher daily ICU costs were significantly associated with higher FS-ICU and QODD-1 (P < .01 and P = .01, respectively); this association was absent for privately insured or Medicare patients (P = .50 and P = .85, QODD-1 and FS-ICU, respectively). However, higher nurse-assessed QODD-1 was significantly associated with lower average daily ICU cost and total hospital cost (P < .01 and P = .05, respectively).
  
  
  CONCLUSIONS
  Family-rated satisfaction with care and quality of dying varied depending on insurance status, with underinsured families rating satisfaction with care and quality of dying higher when average daily ICU costs were higher. However, patients with higher costs were assessed by nurses as having a poorer quality of dying. These findings highlight important differences between family and clinician perspectives and the important role of insurance status.
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA. Electronic address: khandel@uw.edu.
authors.forename: Nita
authors.initials: N
authors.lastname: Khandelwal
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, WA.
authors.forename: David C
authors.initials: DC
authors.lastname: Benkeser
authors.affiliation: Department of Health Services, University of Washington, Seattle, WA.
authors.forename: Norma B
authors.initials: NB
authors.lastname: Coe
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA.
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
mesh_terms: D000328:Adult; D000368:Aged; D001293:Attitude to Death; D003422:Critical Care; D003430:Cross-Sectional Studies; D005195:Family Relations; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007362:Intensive Care Units / Q000191:economics*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010465:Perception; D011788:Quality of Life; D013727:Terminal Care / Q000191:economics* / Q000379:methods*