One in five terminally ill Americans dies in an ICU

ICUs not prepared for end-of-life issues

Although most Americans say they would prefer a low-tech approach to death, the opposite is happening, with more than 20% of terminally ill patients dying in intensive care, according to an article in the March issue of Critical Care Medicine, the journal of the Society of Critical Care Medicine.

"This is the first study to provide national scale to the often discussed end-of-life public health issue," says Derek C. Angus, MD, MPH, professor of critical care medicine and vice chair of research in the department of critical care medicine at the University of Pittsburgh School of Medicine. "Previously there were no reliable estimates of the magnitude of this situation."

In light of their findings, the researchers are concerned that hospitals and intensive care units (ICUs) are not prepared to deliver end-of-life care to the over-65 population, which is rapidly increasing.

The researchers analyzed hospital discharge data from 1999 for six states — Florida, Massachusetts, New Jersey, New York, Virginia, and Washington — and the National Death Index to estimate the use of critical care at the end of life.

The researchers found that of the 552,157 deaths they were studying, 38.3% occurred in the hospital, and 22.4% occurred following ICU admission. Nationally projected, this means more than half a million Americans die annually following ICU admission.

End-of-life ICU use was highest (43%) among infants, ranged from 18% to 26% among older children and adults, and fell to 14% for people older than 85 years.

Additionally, the researchers found that terminally ill ICU patients had an average length of stay of 12.9 days, at a cost of $24,541. Non-ICU hospitalization of the terminally ill had an average stay of 8.9 days, at a cost of $8,548.

Nine of 10 Americans say they would prefer to die at home; however, 20% die after receiving the most technologically advanced care available. This contradiction may be explained by the uncertainty surrounding time-of-death predictions, which is particularly true in acute-care settings where advanced technology is used to prolong life.

The number of Americans who are older than age 65 is expected to double by the year 2030, putting a great deal of stress on ICUs. The researchers recommended a systemwide expansion in ICU care for dying patients unless the health care system pursues an alternative approach.

"Intensive care plays a major role in end-of- life care in the United States," says Angus, who also is director of the CRISMA Laboratory at the University of Pittsburgh School of Medicine. "We have an enormous social and medical imperative to take very seriously our efforts to make sure critical care is only provided when appropriate and provided in a way that has all the elements of compassion and humanism necessary to treat and manage end-of-life care with dignity."

Angus recommends improving prediction models, which help reduce ICU admission at the end of life for patients with a poor prognosis. He suggests critical care physicians partner with referring physicians to consider risk prevention models before admitting terminally ill patients who cannot benefit from critical care.

"Even with excellent prediction models, we will still admit patients at high risk of dying because they also have a good chance of survival," says Angus. "There will still be a large, irreducible number of patients who die in intensive care. This means we have to carefully consider providing and promoting good end-of-life care in the ICU."

Angus says it is difficult for patients, families, and physicians to strike a balance between not wanting to die and not wanting to die badly.

"Some groups of patients are less likely to die in the ICU than others," says Angus. "For instance, HIV/AIDS patients and cancer patients use the ICU less often at the end of life, presumably because they have more clearly established guidelines for their end-of-life care. However, other groups who end up in the ICU at the end of life may do so without forewarning or forethought. Better awareness of what ICU care can offer, and better a priori discussions between patients and their health care providers, might promote more efficient use of intensive care services."

The author of an accompanying editorial in the journal says the study may mark a new beginning for research on the subject. "Along with some other recent data demonstrating interventions for improving the quality of end-of-life care in the ICU, the data from Angus et al provide the basis for a new era in ICU end-of-life care — one in which we move from simple descriptive studies to acknowledging the magnitude of the problem and developing specific, practical interventions aimed at enhancing the quality of care received by dying patients and their loved ones," says Mitchell M. Levy, MD. Levy is professor of medicine at Brown University in Providence, RI. "It is time to move our understanding of the barriers to quality end of life care from the bench to the bedside’ and make our care for those dying in the ICU — something that is inevitable for almost 20% of Americans — more humane and compassionate and of the highest quality."

Research for the study was supported by a grant from The Robert Wood Johnson Foundation of Princeton, NJ.