Discussion
In the USA, approximately 20% of patients die in an ICU, with ICU costs accounting for approximately 20% of all hospital costs.9 Providers often recognize the futility of pursuing invasive, aggressive interventions, such as CPR, at the EOL. However, they may struggle to communicate futility adequately to grieving families. This study examined the factors associated with DNR status at the time of death in a wide range of patients across multiple SICUs, including an evaluation of provider perceived futility. Across multiple SICUs, provider perceived futility—despite being reasonably accurate—was not associated with a higher rate of DNR at time of death. Provider recognition of high-acuity, critically ill patients with poor life expectancy was significantly associated with shorter ICU length of stay; however, it had no significant association with code status at the time of death for our overall patient cohort. On the other hand, provider expectation of death was associated with DNR status at the time of death for non-traumatically injured ICU patients. Taken together, these findings demonstrate missed opportunities of health system recognition and communication around complex EOL issues in vulnerable patient populations, resulting in low value care delivery.
Provider ability to predict futility is variable. There are factors associated with caring for a patient in an ICU that are not able to be currently captured by existing scoring systems. Additionally, our ability as providers to predict death at the time of ICU admission was not reliable, with only one in four deaths in our population classified as expected. Prior studies have implemented EMR-based ‘nudge’ interventions to screen and encourage hospital-based providers to engage in EOL conversations with high-risk patients and families.10 This resulted in improvement in the number of goals-of-care conversations for inpatient and under-represented minorities. The predictive utility of our provider assessment has yet to be studied across the population; however, previous studies of provider assessed futility have also been varied.11 12
Additional communication challenges exist at the EOL in this cohort. In a SICU, where the critical care team is traditionally only a consulting service and not the primary caregiver, challenges also arise in communication of futility as both the primary surgical team and the critical care team share the responsibility of conveying important information to family members. After major surgery, these conversations are particularly challenging in the setting of postoperative complications.13 14 This is similarly reflected in our population where postoperative patients were less likely to be DNR in multivariable regression. Further challenges arise when balancing realistic conversations with overly pessimistic prognostication leading to a self-fulfilling prophecy bias where a patient receives limited or incomplete care due to perceived futility.15 In fact, multiple prior studies have demonstrated that the presence of a DNR status is independently associated with mortality in the ICU.16–18
Communicating perceived futility is particularly challenging in the care of traumatically injured patients, as they are often younger and face devastating, unexpected injury. In our cohort, the burden of penetrating traumatic injury was much more highly experienced by black patients as compared with other races. This contributed to black patients being more likely to remain full code at the time of death, potentially exposing them to aggressive interventions, despite higher rates of expected death in this subgroup. Prior studies have demonstrated that non-white patients were less likely to have DNR orders and similarly less likely to have life-sustaining therapies withdrawn.19 As a result, non-white patients who died in the ICU were more likely to have CPR performed and to have invasive medical interventions such as dialysis and mechanical ventilation. Differences in culturally held beliefs and medical literacy may explain some of these differences, as well as reluctance among minority groups to engage in these conversations.20 However, attributing the entire disparity to mistrust may oversimplify the situation by removing the responsibility of the provider to engage in culturally appropriate conversations about essential issues.
Communication about EOL with diverse patient populations must address culturally sensitive beliefs and practices, as the faith of both physicians and patients helps inform discussions regarding withdrawal.21 Religion and spirituality play an essential role in the approach of many black patients to the process of dying, particularly beliefs that only God has the power to decide life and death.22–24 Conversations regarding EOL must acknowledge commonly held beliefs of some black families in divine miracles carried out by God who acts through physicians, but still shoulders the ultimate responsibility for physical and spiritual health.22 Principles of trauma-informed care, including cultural humility, empathy and transparency, must all be employed in communicating the limits of invasive interventions that may artificially prolong duration of time on this earth while interfering with the ‘home going’ that is promised.
Social cognition and implicit bias must be recognized in these crucial, high-stakes interactions. In other contexts, communication with race concordant physicians has been demonstrated to result in better satisfaction in patient–physician communication.25 26 Cultural sensitivity furthered by providers that more closely represent their patient population may help overcome many of these barriers. The diversification of the critical care workforce may further promote holistic care and reduce unnecessary suffering at the EOL.27 Our study did not collect specific demographic data on the care team for each individual patient, but this may identify opportunities for more effective verbal and non-verbal communication.
Black patients were also less likely to receive palliative care consultation in our study population. On subgroup analysis, this was only true for non-trauma patients and not for our traumatically injured patient cohort. Underuse of palliative care among black patients has previously been described, spanning cultural, spiritual and social patient considerations along with the lack of provider delivery of trauma-informed care.24 The potential benefit of palliative care in this population is complicated, as palliative care consultation in black patients has not always been found to decrease healthcare costs or utilization, as it does in white patients.28 Geographic differences in access to palliative care have also been reported with poorer rural areas being less likely to access palliative care programs.29 Race-based differences in EOL care in the ICU have been previously attributed to differences within health systems that care for black and Hispanic patients rather than differences within the same hospital.30 This study took place across one health system with a similar provider group at every level caring for patients (attendings, advanced practice providers, critical care fellows) with palliative care availability to mitigate such hospital-system influences.
Palliative care consultation across our cohort was associated with increased odds of DNR at the time of death. This was only true for non-traumatically injured patients, but not for traumatically injured patients even after adjusting for race and ICU characteristics in multivariable regression. Palliative care consultation has been associated with higher acuity patients with longer ICU length of stay and higher rates of mortality.31 However, proactive palliative care consultation has been demonstrated to shorten ICU length of stay in a study of patients in the medical ICU.32 Engaging palliative care providers may aid in the communication of expected futility with aggressive intervention.
Our study examined provider assessment of futility and code status at the EOL, identifying lower rates of DNR status in traumatically injured patients, particularly black patients. To address these disparities, we are developing a uniform process of screening for provider assessed futility at the time of SICU admission and adopting a standardized approach to future interventions, including family discussions of goals of care and palliative care consultations. We plan on implementing this initiative in our trauma SICU with the ultimate goal of tailoring expansion to other sites in the hope of promoting culturally sensitive, family-based approach to ICU EOL discussions.
Limitations
Our study has several limitations, namely the retrospective nature of our analysis with data primarily abstracted from EMR chart review. This approach allowed access to concrete data on ICU progression of care, but did not provide the motivation or reasoning for the provider and family decisions that would have required primary chart or even qualitative interviews with the families. Our findings represented a heterogenous patient sample across multiple SICUs, including traumatically injured patients in an urban academic medical center, which may not be applicable to other populations. Our current provider assessment of futility is also subject to observer bias, particularly as it related to racial differences within our population. Our analysis also did not account for many of the important social determinants of health, such as insurance status, primary language, and household income, and other essential factors which influence health outcomes and discussions regarding EOL care.
Additionally, missing data due to failed EMR linkage in 18% of patients in our SICU registry which were not able to be linked to the EMR introduce the potential of bias of our findings related to the critical care interventions such as timing of code status change and presence of palliative care consultation (online supplemental figure 1). This is likely due to the multiplicity of medical record numbers per patient registered into our multihospital health system or provider entry error into the registry. When comparing characteristics between patients successfully linked to the EMR versus not, there were significant differences between race, injury mechanism and operative intervention (online supplemental table 3). While this may confound our findings regarding the utility of palliative consultation, our primary findings regarding code status and race remain unchanged. While the collinearity of age and race with admission diagnosis is also a potential confounder in our population, limiting the generalizability of our results, they also provide opportunities for local quality improvement initiatives.
