Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

Background A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making. Methods A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record. Results The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death ( P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days ( P = .09), time to decision to limit any life support was shortened by 1 day ( P = .08), time to death was shortened by 2 days ( P = .08), and intubations against patient wishes decreased (from three to none; P = .12). Conclusions The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.