NEW YORK (October 22, 2009) – A new study has found that half of all hospital deaths involve intensive care in the United States, compared with only one in ten in England, indicating that end-of-life care in the two countries is very different, despite similar life expectancies among the two countries.
The findings come at a crucial time when the United States is considering landmark health care legislation and there is broad concern among U.S. citizens regarding the provision and cost of health care at the end of life. Although anecdotes of country-specific differences are common, comprehensive evaluations of differences in care have rarely been conducted.
Hannah Wunsch, M.D.
The study, led by Hannah Wunsch, M.D., and her colleagues from Columbia University Medical Center, the University of Pittsburgh, and the British Intensive Care National Audit and Research Center, is being published in the Nov. 1, 2009 edition of the American Journal of Respiratory and Critical Care Medicine.
More deaths in England occur in hospitals compared with the United States, but the use of intensive care during terminal hospitalizations was much higher in the United States, researchers found. The study included all persons discharged from Britain’s National Health Service (NHS) Trust Acute Care Hospitals in England and from hospitals in seven states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia and Washington) in the United States from January 1, 2001 through December 31, 2001. Researchers used data from 2001 to coincide with the most recent accurate population-based census data from the two countries.
The largest divergence in use appeared to be among older people, the study found. In England, there was almost no use of intensive care services among those age 85 years and older who died in the hospital, said Columbia’s Dr. Wunsch, the lead author of the study.
“These are impressive differences and very relevant to our current debate about possible directions we can move to reshape health care,” said Dr. Wunsch, assistant professor of anesthesiology and critical care medicine at Columbia University. “The finding that so many more people in the United States receive intensive care before death compared with England raises the question of whether we can improve our delivery of health care without compromising quality.”
Further study will be needed to address the many factors that likely influence the differing patterns of care at the end of life in these two countries. From a legal perspective, who makes decisions regarding treatment for incapacitated patients, however, varies between the countries: in England, decisions regarding care usually rest with the clinician, whereas the U.S. model places much more emphasis on the autonomy of the patient and/or family decision-makers.
“Intensive care is tough love. Although it can be life-saving, it is often invasive and aggressive, not to mention dangerous and expensive. Thus, no one wants to provide unnecessary or futile intensive care,” said Derek C. Angus, senior author of the study and chair of the Department of Critical Care Medicine at the University of Pittsburgh School of Medicine. “The trick is knowing just when and where it should be used.”
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