1 Background: Advanced life support resources are required for optimal care of patients undergoing curative therapy, but their use in patients with terminal disease does not improve patient outcomes. In 2007, our cancer center established the Duffey Pain and Palliative Care team, and one important goal was to help our physicians improve at discussing end-of-life issues with patients. We hypothesized that if this effort was effective, it would result in less utilization of intensive care unit (ICU) management among patients who die in the center. Methods: All inpatient deaths were systematically tabulated and code status displayed at the multidisciplinary Morbidity and Mortality review twice per quarter, beginning in July 2006. Utilization of ICU care, defined as ventilator or dialysis support, was identified from billing data and confirmed by chart review. Survival to discharge among patients who received ICU care was monitored as a component of our patient safety dashboard. Results: From 2008 through 2011, 525 oncology patients died while hospitalized in the cancer center. During this period, among patients who died, there was a gradual increase in no-code status, election of comfort care, or withdrawal of ICU support, from 81% to 95% (OR 1.14 per quarter, p<0.0001). Although the proportion of patients who received any ICU care during their terminal hospitalization did not change, the duration of such care decreased: the proportion with mechanical ventilation for over 14 days decreased from 10% to 5% (OR 0.93 per quarter, p<0.05). There was no decrease in the survival-to-discharge of patients who received ICU care. Conclusions: A multidisciplinary team approach to improve discussion of end-of-life issues, combined with regular feedback to cancer center staff regarding code status at death, resulted in significant changes in patient and family decisions about management at the end of life over a four-year interval. These changes have reduced utilization of ICU care during terminal hospitalizations with no reduction in the survival-to-discharge of all patients who receive ICU care. We propose appropriate establishment of code status and survival-to-discharge of ICU patients as measures of quality oncology care.
The Conundrum of the End of Life Issues in the Intensive Care Unit
