We, therefore, encourage standard bronchoscopy with conventional tools in the appropriate clinical setting and propose the notion of “choosing wisely,” wherein both pulmonologists and institutions select their techniques and investments based on their patient population and available skills.
Variability in Decisions to Limit Life-Sustaining Treatments
Acknowledgments
J. Randall Curtis, MD, MPH
Other contributions: We thank Nirupama Mulherkar, PhD, for writing assistance.
Seattle, WA
Is It All About the Physician? Amber E. Barnato, MD, MPH Pittsburgh, PA
References 1. Indiana Jones and the Last Crusade. Dir: Steven Spielberg. Paramount Pictures, 1989. Film. 2. Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;98(4 pt 1):298-300. 3. von Bartheld MB, Dekkers OM, Szlubowski A, et al. Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23):2457-2464. 4. Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. 5. Culver DA, Costabel U. EBUS-TBNA for the diagnosis of sarcoidosis: is it the only game in town? J Bronchology Interv Pulmonol. 2013;20(3):195-197. 6. Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78(1):65-71. 7. Reich JM, Brouns MC, O’Connor EA, Edwards MJ. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis. Chest. 1998;113(1):147-153. 8. Reich JM. Tissue confirmation of presumptive stage I sarcoidosis. J Bronchology Interv Pulmonol. 2013;20(2):103-105. 9. Narula T, Baughman RP, Mehta AC. “Sarcoidosis Americana-route Europa.” J Bronchology Interv Pulmonol. 2013;20(4):293-296. 10. Mehta AC, Mazzone PJ. An attempt to reach the galaxy of the pulmonary nodules. Am J Respir Crit Care Med. 2013;188(3): 264-265. 11. Mehta AC, Wang KP. Teaching conventional transbronchial needle aspiration. A continuum. Ann Am Thorac Soc. 2013;10(6): 685-689. 12. Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556. 13. de Boer S, Milne DG, Zeng I, Wilsher ML. Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis? Thorax. 2009;64(5):436-439. 14. Ribeiro Neto ML, Culver DA, Mehta AC. Sarcoidosis—no business of the bronchoscopist. J Thorac Cardiovasc Surg. 2012;144(5):1276-1277. 15. Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. 16. Hernández Blasco L, Sánchez Hernández IM, Villena Garrido V, de Miguel Poch E, Nuñez Delgado M, Alfaro Abreu J. Safety of the transbronchial biopsy in outpatients. Chest. 1991;99(3):562-565. 17. Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. 18. Plit ML, Havryk AP, Hodgson A, et al. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J. 2013;42(5):1302-1308. 19. Cicenia J, Almeida F, Machuzak M, et al. The utility of rapid on-site evaluation (ROSE) in the detection of granulomas in mediastinal lymph nodes. Chest. 2013;144(4_MeetingAbstracts):797A.
532 Editorials
Approximately 20% of deaths in the United States occur in or shortly after a stay in the ICU, and the proportion of Medicare beneficiaries who spend time in the ICU in the last 30 days of their lives is increasing.1,2 Of the deaths occurring in the ICU, the majority involve decisions to withhold or withdraw life-sustaining treatments. Studies from the past century documented dramatic variability from ICU to ICU in the proportion of deaths preceded by withholding and withdrawing life-sustaining treatments.3 An article by Quill and colleagues4 in this issue of CHEST (see page 573) shows that dramatic variability persists—sixfold—in these decisions from ICU to ICU, even after adjusting for patient and ICU factors. Why might this variability exist? If such variability is explained by systematic variability from ICU to ICU in patient or family preferences for care at the end of life, it might be an indication of patient- and family-centered care. However, this is unlikely. Although there is regional variability in patient preferences for end-of-life care, the variability in intensity of care at the end of life is not explained by variability in patient preferences.5 Indeed, there is compelling evidence that considerable variability in decision-making about withdrawing life support in the ICU is explained by individual physicians, even after adjusting for patient characteristics.6 AFFILIATIONS:
From the Division of Pulmonary and Critical Care Medicine (Dr Curtis), Harborview Medical Center, University of Washington; and Division of General Internal Medicine (Dr Barnato), Department of Medicine, University of Pittsburgh. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: J. Randall Curtis, MD, MPH, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0636
[
146#3 CHEST SEPTEMBER 2014
]
In addition, physicians practicing in a given ICU may be governed by hospital-specific norms of decision-making regarding end-of-life care, as revealed in a case study of two US hospitals with very different intensity of care at the end of life.7 Studies in Europe also demonstrated regional variability in decision-making about end-of-life care in the ICU and documented important variability by religion of the physicians in the ICU.8 It is difficult in these observational studies to separate the cultural norms of physicians from those of patients and family members, but these studies nonetheless raise the possibility that variability in end-of-life decision-making in the ICU is principally driven by the views of physicians in the ICU. Another potentially controversial finding in the study by Quill and colleagues4 is that black race varied from being associated with a fivefold decrease in the odds of limiting life-sustaining treatments in some ICUs to a 2.5-fold increase in the odds of limiting life-sustaining treatments in other ICUs. This contrasts the finding that other demographic factors, such as advanced age and female sex, are consistently associated with increased odds of deciding to limit life-sustaining treatments across ICUs. Importantly, the race finding may be influenced by sampling error because only one of the 15 ICUs with a point estimate for the odds of limiting life support among blacks . 1 was statistically significant. Ultimately, the variation between ICUs in their probability of limiting life-sustaining treatments is more likely to determine the treatment that black patients in those ICUs receive than their treatment compared with whites in the same ICU because of the unequal distribution of blacks across hospitals.9 Furthermore, differences in sociodemographics, such as education, insurance, and religion, may confound the relationship between race/ethnicity and intensity of care at the end of life. Importantly, if confounding were to explain the finding that blacks are more likely to be treated intensively than whites in some ICUs and less likely to be treated intensively than whites in other ICUs, then the third variable, such as religious beliefs predicting preferences not to limit life support, would have been more common among blacks in the former but more common in whites in the latter. Although we often invoke explanations like confounding to explain disturbing findings by race, the real explanations are undoubtedly more complicated because important differences in end-of-life care in the ICU by patient race/ethnicity are not explained by socioeconomic variables.10 Ultimately, to provide the most appropriate
journal.publications.chestnet.org
intensity of care at the end of life, we must be able to separate racial/ethnic differences in preferences for care that are based on the values of fully informed patients and families from differences due to disparities in the way end-of-life care is discussed or delivered. Differences based on the preferences of informed patients and families should be honored and incorporated; differences based on disparities in the way care is discussed or delivered should be eradicated. Another interesting finding from this article is that ICUs with a higher propensity to limit life-sustaining treatments had a higher standardized mortality ratio.4 On the contrary, a study from Italy found the exact opposite: ICUs with a higher propensity to limit life-sustaining treatments had a lower standardized mortality ratio.11 These findings require additional study to understand, but it is possible that in Italy, where decisions to limit life-sustaining treatment are less common and a more recent phenomenon, such decisions may be more likely to occur in ICUs that have incorporated the newest approaches to ICU safety and quality. In the United States, where decisions to withdraw life-sustaining treatment have been in place much longer, other factors may play a key role. For example, discharge to long-term acute care facilities can have a large influence on ICU mortality in the United States, and it is possible that decisions limiting life-sustaining treatments occur less in ICUs with more use of these facilities, which might artificially lower the standardized mortality ratio.12 These potential explanations are highly speculative and will require additional investigation. Regardless of the explanation for these conflicting findings, it is important to point out that quality of care is a multifactorial construct that includes many aspects of care in addition to standardized mortality ratios, such as implementation of state-of-the-art medical care, communication with patients and families, and patient and family satisfaction with care. The decision to limit life-sustaining treatments in the ICU varies widely from ICU to ICU, and the factors explaining this variability are not entirely clear. In an ideal world, such variability should depend primarily on severity of illness, prognosis for survival and quality of life, and patient and family goals and preferences. There is evidence that much of the current variability is not driven by these factors but, rather, by physicians and ICU culture. Physicians clearly need to be centrally involved in shared decision-making about life-sustaining treatments in the ICU, but dramatic variability in decision-making that is based on the perspectives of
533
individual physicians is profoundly problematic. Ongoing research and education to develop and implement best practices for communication and shared decision-making within the clinical team and with the patient and family are critical to address this important problem.
References 1. Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. 2. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5): 470-477. 3. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1167. 4. Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD. Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest. 2014;146(3):573-582.
534 Editorials
5. Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences? A study of the US Medicare population. Med Care. 2007;45(5):386-393. 6. Garland A, Connors AF. Physicians’ influence over decisions to forego life support. J Palliat Med. 2007;10(6):1298-1305. 7. Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med. 2012;38(11):1886-1896. 8. Sprung CL, Maia P, Bulow HH, et al; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33(10):1732-1739. 9. Barnato AE, Berhane Z, Weissfeld LA, Chang CC, Linde-Zwirble WT, Angus DC; Robert Wood Johnson Foundation ICU End-ofLife Peer Group. Racial variation in end-of-life intensive care use: a race or hospital effect? Health Serv Res. 2006;41(6):2219-2237. 10. Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest. 2011;139(5):1025-1033. 11. Bertolini G, Boffelli S, Malacarne P, et al. End-of-life decisionmaking and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med. 2010;36(9):1495-1504. 12. Kahn JM, Werner RM, Carson SS, Iwashyna TJ. Variation in long-term acute care hospital use after intensive care. Med Care Res Rev. 2012;69(3):339-350.
[
146#3 CHEST SEPTEMBER 2014
]
Variability in Decisions to Limit Life-Sustaining Treatments
Acknowledgments
J. Randall Curtis, MD, MPH
Other contributions: We thank Nirupama Mulherkar, PhD, for writing assistance.
Seattle, WA
Is It All About the Physician? Amber E. Barnato, MD, MPH Pittsburgh, PA
References 1. Indiana Jones and the Last Crusade. Dir: Steven Spielberg. Paramount Pictures, 1989. Film. 2. Wang KP, Fuenning C, Johns CJ, Terry PB. Flexible transbronchial needle aspiration for the diagnosis of sarcoidosis. Ann Otol Rhinol Laryngol. 1989;98(4 pt 1):298-300. 3. von Bartheld MB, Dekkers OM, Szlubowski A, et al. Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23):2457-2464. 4. Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. 5. Culver DA, Costabel U. EBUS-TBNA for the diagnosis of sarcoidosis: is it the only game in town? J Bronchology Interv Pulmonol. 2013;20(3):195-197. 6. Winterbauer RH, Belic N, Moores KD. Clinical interpretation of bilateral hilar adenopathy. Ann Intern Med. 1973;78(1):65-71. 7. Reich JM, Brouns MC, O’Connor EA, Edwards MJ. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis. Chest. 1998;113(1):147-153. 8. Reich JM. Tissue confirmation of presumptive stage I sarcoidosis. J Bronchology Interv Pulmonol. 2013;20(2):103-105. 9. Narula T, Baughman RP, Mehta AC. “Sarcoidosis Americana-route Europa.” J Bronchology Interv Pulmonol. 2013;20(4):293-296. 10. Mehta AC, Mazzone PJ. An attempt to reach the galaxy of the pulmonary nodules. Am J Respir Crit Care Med. 2013;188(3): 264-265. 11. Mehta AC, Wang KP. Teaching conventional transbronchial needle aspiration. A continuum. Ann Am Thorac Soc. 2013;10(6): 685-689. 12. Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556. 13. de Boer S, Milne DG, Zeng I, Wilsher ML. Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis? Thorax. 2009;64(5):436-439. 14. Ribeiro Neto ML, Culver DA, Mehta AC. Sarcoidosis—no business of the bronchoscopist. J Thorac Cardiovasc Surg. 2012;144(5):1276-1277. 15. Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. 16. Hernández Blasco L, Sánchez Hernández IM, Villena Garrido V, de Miguel Poch E, Nuñez Delgado M, Alfaro Abreu J. Safety of the transbronchial biopsy in outpatients. Chest. 1991;99(3):562-565. 17. Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. 18. Plit ML, Havryk AP, Hodgson A, et al. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J. 2013;42(5):1302-1308. 19. Cicenia J, Almeida F, Machuzak M, et al. The utility of rapid on-site evaluation (ROSE) in the detection of granulomas in mediastinal lymph nodes. Chest. 2013;144(4_MeetingAbstracts):797A.
532 Editorials
Approximately 20% of deaths in the United States occur in or shortly after a stay in the ICU, and the proportion of Medicare beneficiaries who spend time in the ICU in the last 30 days of their lives is increasing.1,2 Of the deaths occurring in the ICU, the majority involve decisions to withhold or withdraw life-sustaining treatments. Studies from the past century documented dramatic variability from ICU to ICU in the proportion of deaths preceded by withholding and withdrawing life-sustaining treatments.3 An article by Quill and colleagues4 in this issue of CHEST (see page 573) shows that dramatic variability persists—sixfold—in these decisions from ICU to ICU, even after adjusting for patient and ICU factors. Why might this variability exist? If such variability is explained by systematic variability from ICU to ICU in patient or family preferences for care at the end of life, it might be an indication of patient- and family-centered care. However, this is unlikely. Although there is regional variability in patient preferences for end-of-life care, the variability in intensity of care at the end of life is not explained by variability in patient preferences.5 Indeed, there is compelling evidence that considerable variability in decision-making about withdrawing life support in the ICU is explained by individual physicians, even after adjusting for patient characteristics.6 AFFILIATIONS:
From the Division of Pulmonary and Critical Care Medicine (Dr Curtis), Harborview Medical Center, University of Washington; and Division of General Internal Medicine (Dr Barnato), Department of Medicine, University of Pittsburgh. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: J. Randall Curtis, MD, MPH, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0636
[
146#3 CHEST SEPTEMBER 2014
]
In addition, physicians practicing in a given ICU may be governed by hospital-specific norms of decision-making regarding end-of-life care, as revealed in a case study of two US hospitals with very different intensity of care at the end of life.7 Studies in Europe also demonstrated regional variability in decision-making about end-of-life care in the ICU and documented important variability by religion of the physicians in the ICU.8 It is difficult in these observational studies to separate the cultural norms of physicians from those of patients and family members, but these studies nonetheless raise the possibility that variability in end-of-life decision-making in the ICU is principally driven by the views of physicians in the ICU. Another potentially controversial finding in the study by Quill and colleagues4 is that black race varied from being associated with a fivefold decrease in the odds of limiting life-sustaining treatments in some ICUs to a 2.5-fold increase in the odds of limiting life-sustaining treatments in other ICUs. This contrasts the finding that other demographic factors, such as advanced age and female sex, are consistently associated with increased odds of deciding to limit life-sustaining treatments across ICUs. Importantly, the race finding may be influenced by sampling error because only one of the 15 ICUs with a point estimate for the odds of limiting life support among blacks . 1 was statistically significant. Ultimately, the variation between ICUs in their probability of limiting life-sustaining treatments is more likely to determine the treatment that black patients in those ICUs receive than their treatment compared with whites in the same ICU because of the unequal distribution of blacks across hospitals.9 Furthermore, differences in sociodemographics, such as education, insurance, and religion, may confound the relationship between race/ethnicity and intensity of care at the end of life. Importantly, if confounding were to explain the finding that blacks are more likely to be treated intensively than whites in some ICUs and less likely to be treated intensively than whites in other ICUs, then the third variable, such as religious beliefs predicting preferences not to limit life support, would have been more common among blacks in the former but more common in whites in the latter. Although we often invoke explanations like confounding to explain disturbing findings by race, the real explanations are undoubtedly more complicated because important differences in end-of-life care in the ICU by patient race/ethnicity are not explained by socioeconomic variables.10 Ultimately, to provide the most appropriate
journal.publications.chestnet.org
intensity of care at the end of life, we must be able to separate racial/ethnic differences in preferences for care that are based on the values of fully informed patients and families from differences due to disparities in the way end-of-life care is discussed or delivered. Differences based on the preferences of informed patients and families should be honored and incorporated; differences based on disparities in the way care is discussed or delivered should be eradicated. Another interesting finding from this article is that ICUs with a higher propensity to limit life-sustaining treatments had a higher standardized mortality ratio.4 On the contrary, a study from Italy found the exact opposite: ICUs with a higher propensity to limit life-sustaining treatments had a lower standardized mortality ratio.11 These findings require additional study to understand, but it is possible that in Italy, where decisions to limit life-sustaining treatment are less common and a more recent phenomenon, such decisions may be more likely to occur in ICUs that have incorporated the newest approaches to ICU safety and quality. In the United States, where decisions to withdraw life-sustaining treatment have been in place much longer, other factors may play a key role. For example, discharge to long-term acute care facilities can have a large influence on ICU mortality in the United States, and it is possible that decisions limiting life-sustaining treatments occur less in ICUs with more use of these facilities, which might artificially lower the standardized mortality ratio.12 These potential explanations are highly speculative and will require additional investigation. Regardless of the explanation for these conflicting findings, it is important to point out that quality of care is a multifactorial construct that includes many aspects of care in addition to standardized mortality ratios, such as implementation of state-of-the-art medical care, communication with patients and families, and patient and family satisfaction with care. The decision to limit life-sustaining treatments in the ICU varies widely from ICU to ICU, and the factors explaining this variability are not entirely clear. In an ideal world, such variability should depend primarily on severity of illness, prognosis for survival and quality of life, and patient and family goals and preferences. There is evidence that much of the current variability is not driven by these factors but, rather, by physicians and ICU culture. Physicians clearly need to be centrally involved in shared decision-making about life-sustaining treatments in the ICU, but dramatic variability in decision-making that is based on the perspectives of
533
individual physicians is profoundly problematic. Ongoing research and education to develop and implement best practices for communication and shared decision-making within the clinical team and with the patient and family are critical to address this important problem.
References 1. Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. 2. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5): 470-477. 3. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1167. 4. Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD. Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest. 2014;146(3):573-582.
534 Editorials
5. Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences? A study of the US Medicare population. Med Care. 2007;45(5):386-393. 6. Garland A, Connors AF. Physicians’ influence over decisions to forego life support. J Palliat Med. 2007;10(6):1298-1305. 7. Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med. 2012;38(11):1886-1896. 8. Sprung CL, Maia P, Bulow HH, et al; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33(10):1732-1739. 9. Barnato AE, Berhane Z, Weissfeld LA, Chang CC, Linde-Zwirble WT, Angus DC; Robert Wood Johnson Foundation ICU End-ofLife Peer Group. Racial variation in end-of-life intensive care use: a race or hospital effect? Health Serv Res. 2006;41(6):2219-2237. 10. Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest. 2011;139(5):1025-1033. 11. Bertolini G, Boffelli S, Malacarne P, et al. End-of-life decisionmaking and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med. 2010;36(9):1495-1504. 12. Kahn JM, Werner RM, Carson SS, Iwashyna TJ. Variation in long-term acute care hospital use after intensive care. Med Care Res Rev. 2012;69(3):339-350.
[
146#3 CHEST SEPTEMBER 2014
]
