New obstacles to improving the quality of end-of-life care in ICU

Abstract

Background Because of high mortality, end-of-life care is an important component of intensive care. Methods Objective To evaluate the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. Design Cluster-randomized trial of a multi-component educational intervention targeted at bedside ICU caregivers from 2004 to 2008. Setting 12 community hospitals in Washington State, United States. Subjects 2,318 patients dying in the ICU or within 30 hours of ICU discharge, as well as their families and the nurses participating in their care. Intervention The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes Quality of death and dying (QODD) and satisfaction surveys. Results The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was also no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a non-significant 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 A multifaceted quality improvement intervention was associated with no improvement in quality of dying among ICU decedents, as well as no reduction in resource utilization prior to the withdrawal of life sustaining measures.