Factors Influencing the Use of Intensive Procedures at the End of Life

Objectives To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life. Design Retrospective cohort study. Setting The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults. Participants HRS decedents aged 66 and older (N = 3,069). Measurements Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life. Results Approximately 18% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85–94 (vs 65–74, adjusted odds ratio (AOR) = 0.67, 95% confidence interval (CI) = 0.51–0.90), Alzheimer's disease (AOR = 0.71, 95% CI = 0.54–0.94), cancer (AOR = 0.60, 95% CI = 0.43–0.85), nursing home residence (AOR = 0.70, 95% CI = 0.50–0.97), and having an advance directive (AOR = 0.71, 95% CI = 0.57–0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95% CI = 1.48–3.13) and black race (AOR = 2.02, 95% CI = 1.52–2.69) each doubled one's odds of undergoing an intensive procedure. Conclusion Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.