Objectives: To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life.
Design: Retrospective cohort study.
Setting: The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults.
Participants: HRS decedents aged 66 and older (N = 3,069).
Measurements: Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life.
Results: Approximately 18% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85-94 (vs 65-74, adjusted odds ratio (AOR) = 0.67, 95% confidence interval (CI) = 0.51-0.90), Alzheimer's disease (AOR = 0.71, 95% CI = 0.54-0.94), cancer (AOR = 0.60, 95% CI = 0.43-0.85), nursing home residence (AOR = 0.70, 95% CI = 0.50-0.97), and having an advance directive (AOR = 0.71, 95% CI = 0.57-0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95% CI = 1.48-3.13) and black race (AOR = 2.02, 95% CI = 1.52-2.69) each doubled one's odds of undergoing an intensive procedure.
Conclusion: Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.
Keywords: Medicare; end-of-life decisions; intensive care; terminal care.
© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.