Author(s): Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR
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Abstract BACKGROUND: There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status. METHODS: We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. RESULTS: Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79\%) were white and 659 (21\%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95\% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95\% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95\% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95\% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95\% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. CONCLUSIONS: We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
This article was published in Chest
and referenced in Internal Medicine: Open Access