Advance care planning norms may contribute to hospital variation in end-of-life ICU use: a simulation study

Med Decis Making. 2014 May;34(4):473-84. doi: 10.1177/0272989X14522099. Epub 2014 Mar 10.


Background: There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation.

Methods: This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning.

Results: Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a do-not-resuscitate order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient's known metastatic gastric cancer in the context of norms of oncologists' avoiding code status discussions.

Conclusions: In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.

Keywords: Medicare; cancer; heuristics; intensive care; national health policy; palliative care; physician decision making; qualitative research; simulation; terminal care; variation.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Academic Medical Centers / organization & administration
  • Academic Medical Centers / statistics & numerical data
  • Adult
  • Advance Care Planning / statistics & numerical data*
  • Decision Making*
  • Female
  • Humans
  • Intensive Care Units / organization & administration
  • Intensive Care Units / statistics & numerical data*
  • Male
  • Middle Aged
  • Patient Care Planning / organization & administration
  • Patient Care Planning / statistics & numerical data*
  • Patient Simulation
  • Physicians
  • Prognosis
  • Terminal Care / organization & administration
  • Terminal Care / statistics & numerical data*