Journal
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Volume 183, Issue 3, Pages 348-355Publisher
AMER THORACIC SOC
DOI: 10.1164/rccm.201006-1004OC
Keywords
cluster randomized trial; critical care; withdrawal of life support; end-of-life care; palliative care
Categories
Funding
- National Institute of Nursing Research [R01 NR05226]
- Robert Wood Johnson Foundation
- Advanced Lifeline Systems
- Siemens
- Bayer
- Byk-Gulden
- AstraZeneca
- DHD
- Lilly
- Hospira
- Cerner
- Pfizer
- KCI
- American Association for Respiratory Care
- American Thoracic Society
- Alberta Heritage Foundation for Medical Research
- Faron Pharmaceuticals
- Cerus Corporation
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Rationale: Because of high mortality, end-of-life care is an important component of intensive care. Objectives: We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. Methods: We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. Measurements and Main Results: All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). Conclusions: We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families.
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