An Alternative Approach to Understanding the Drivers of High-Performance End-of-life Care Delivery in the Intensive Care Unit

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PROJECT SUMMARY/ABSTRACT The overall goal of this research proposal is to facilitate the candidate's development as an independently-funded surgeon scientist with a focus on bioethics-oriented health services, outcomes, and quality improvement research. The candidate and her mentors have also designed a robust training plan consisting of regular mentorship and formal didactic coursework in research methodologies and bioethics. With this proposed NRSA individual fellowship application, the candidate will focus on career development while also building skills in both quantitative and qualitative research methods by studying the delivery of end-of-life (EOL) care in intensive care units (ICU) at Northwestern Memorial Hospital (NMH). A large number of adults in the United States are admitted to ICUs near their end of life. About 20 to 30 percent of them die using ICU services and many more receive care that is discordant to their wishes. Wide discrepancies exist in how EOL care is delivered. The range in practice patterns cannot be explained by patient and unit-level characteristics. EOL care is not standardized and quality measures require validation. Furthermore, identifying latent, unit-level structures, processes, and culture that impact patients' EOL experiences are unrealized opportunities for improvement. NMH has five different ICUs that operate independently of each other. We hypothesize that amongst these ICUs there is variability in the process and outcomes of EOL care delivery. We will use a mixed-methods approach to identify latent unit level differences that can be attributed to the structure, process, and culture of a given ICU. From the electronic health record (EHR), we will find measurable and recordable data on EOL quality metrics. Then through a positive-deviant framework, involving an ethnographic case study and semi-structured interviews of the ICU clinicians, our goal is to uncover practice patterns associated with high-performance on specific EOL care domains. The proposed project is innovative because it is the first time measuring domains of EOL care while also studying the environments from which these patients receive care. The systematic analysis of the complex influences on EOL care delivery will lead us towards unit level interventions to improve ICU patient care in the future.