Original Investigation 

Less Is More

July 3, 2023

Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers

Elizabeth Dzeng, Jason N. Batten, Daniel Dohan, et al

JAMA Intern Med. Published online July 3, 2023. doi:10.1001/jamainternmed.2023.2450

Key Points

Question  What is the role of hospital culture and institutional structures in the provision of potentially nonbeneficial, high-intensity life-sustaining treatments near the end of life?

Finding  In this qualitative study, 113 semistructured, in-depth interviews were conducted with hospital-based clinicians and administrators at 3 academic hospitals in California and Washington. Hospital culture tended to be aligned with institutional structures (eg, policies, practices, protocols, and resources), which together shaped the provision of potentially nonbeneficial life-sustaining treatments for patients near the end of life at each site.

Meaning  The findings of this study suggest that institutional cultures should be considered when developing policies and interventions to mitigate nonbeneficial, high-intensity life-sustaining treatments for patients near the end of life.

Abstract

Importance  There is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life.

Objective  To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.

Design, Setting, and Participants  This comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.

Main Outcome and Measure  Institution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments.

Results  A total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient’s care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.

Conclusions and Relevance  In this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments.