Article Reviews
Use of Intensive Care Services during Terminal Hospitalisations in England and the United States
by Neil Orford - Biography
The Paper
Title: Use of Intensive Care Services during Terminal Hospitalisations in England and the United States
Authors: Wunsch H, Linde-Zwirble W, Harrison D, Barnato A, Rowan K, Angus D.
Journal: American Journal of Respiratory and Critical Care Medicine. 2009;180(9):875-880
Overview: This study aimed to assess the difference between England and the United States in use of hospital and intensive care services for patients who subsequently died.
The study was designed as 1-year retrospective cohort study, including all patients admitted to hospital in England and 7 states of the US in 2001. From multiple databases data was collected on hospitalisation and death rates with and without intensive care.
From the two large databases (5,726,709 hospital discharges England, 8,462,172 hospital discharges US) the comparisons were;
· total death rate per 1,000 population was the same (0.9/1000).
· US compare to England
o Less deaths occurring in hospitals (50.3% vs 36.6%)
o More hospital patients receiving intensive care (2.2% E, 19.3% US)
o Lower hospital mortality for patients receiving ICU higher (19.6% E, 7.4% US)
o More deaths involving intensive care (5.1% E, 17.2% US).
o Deaths in the hospital higher
o >85 years less die in hospital (31% US, 47% E), but more use ICU before death (11% Us, 1.3% E)
o Higher use by surgical than medical decedents’ in both countries
The patterns of hospital care before death differ markedly between the US and England. Despite more deaths occurring in hospital in England, the use if ICU’s before death was 4-fold higher in the US, with a lower mortality for all ICU patients. The possible reasons for this dramatic difference include the lower number of ICU beds per capita in the UK, differences to end-of-life care with a greater emphasis on limiting treatment in the UK, and differences in definition of “ICU” between the two countries.
Reviewers summary: Although there are possible methodological issues that can account for some of this difference in care (eg definition of ICU beds), the results of this study suggests the process of dying in 1st world countries is not an evidence-based practice. Whether it could or should be is a matter that involves clinicians, community groups, governments, religions, and health institutions.