Quality of End-of-Life Care and Its Association with Nurse Practice Environments in U.S. Hospitals

J Am Geriatr Soc. 2019 Feb;67(2):302-308. doi: 10.1111/jgs.15671. Epub 2018 Dec 2.


Objectives: The purpose of this study is twofold: (1) to describe the quality of end-of-life care in US hospitals from the perspective of hospital nurses; and (2) to evaluate the relationship between the nurse practice environment and end-of-life care quality.

Design: Cross-sectional analysis of multiple linked secondary data sources.

Participants and setting: A total of 12,870 direct care registered nurses in 491 acute-care hospitals.

Measurements: Measures of end-of-life care quality and nurse practice environment were derived from the 2016 RN4CAST-US survey of nurses. Nurses reported on end-of-life care quality for patients for whom death within a year would not be surprising. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a National Quality Forum validated scale.

Results: Most nurses gave their hospitals an unfavorable evaluation of end-of-life care overall (58%) and said patients often experience painful procedures that were unlikely to change their outcome (53%). The best predictor of poor quality was the nurse practice environment. Nurses in the best environments were 55% less likely than nurses in poor environments to rate their hospital's overall end-of-life care quality unfavorably (odds ratio = 0.45; 95% confidence interval = 0.39-0.52; P < .001).

Conclusion: Quality of end-of-life care in US hospitals is imperfect and is significantly worse in hospitals with poor nurse practice environments than in hospitals with the best environments. This study reinforces the importance of nurses in providing high-quality end-of-life care. J Am Geriatr Soc 67:302-308, 2019.

Keywords: end of life; hospitals; quality.

Publication types

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

MeSH terms

  • Adult
  • Cross-Sectional Studies
  • Female
  • Hospitals / standards*
  • Humans
  • Male
  • Middle Aged
  • Nursing Staff, Hospital / psychology*
  • Practice Patterns, Nurses' / standards
  • Quality of Health Care / standards*
  • Terminal Care / standards*
  • United States
  • Workplace / psychology*