ICU stay before death common in the U.S.

NEW YORK Fri Oct 23, 2009 5:22pm EDT

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NEW YORK (Reuters Health) - People who die in a U.S. hospital are nearly five times as likely as their counterparts in England to have spent part of their final hours in an intensive care unit (ICU).

What's more, over the age of 85, ICU usage among terminal patients is eight times higher in the U.S. than in England.

Intensive care services are expensive and labor intensive, Dr. Hannah Wunsch, an anesthesiologist and intensive care doctor at Columbia University Hospital in New York noted in an interview with Reuters Health.

Intensive care is "painful, it's distressing, it's noisy, and it's upsetting to patients and families to be in ICU. It's not something you want if the outcome is not going to be favorable," Wunsch said.

In the study, Wunsch and colleagues compared the records of 493,054 patients who died in 2001 in England with those of 704,028 patients who died in 2001 in seven U.S. states.

While the outcome was the same for all patients, the use of intensive care was quite different between the two countries especially among the oldest patients -- those 85 years old and older.

Roughly half of all hospital deaths in the United States involved intensive care, compared with only 1 in 10 in England, the researchers found.

Generally, U.S. patients of all ages were four times more likely to have used costly intensive care services at the end of life than patients in England.

After age 85, the disparity in ICU usage between the United States and England was more than double that - 11 percent of the U.S. patients versus 1.3 percent of the English patients.

Yet, on average, the British live longer than Americans which begs the question "what do we get with all this intensive care we're giving people?" Wunsch said.

The U.S. has more ICU beds per capita than England and it uses them. When the benefits are not apparent, the questions are "why" and "what's right?" These are questions being asked now in the United States as policy makers debate the correct path to major health care reform.

"Whether less intensive care for very elderly patients who are dying is a form of rationing, or is actually better recognition of what constitutes appropriate care at the end of life warrants further research," Wunsch noted in a prepared statement.

The current findings, published this week in the American Journal of Respiratory and Critical Care Medicine, "highlight the urgent need to understand whether there is over-use of intensive care in the U.S., or under-use in England," Wunsch said.

In a related commentary, Dr. Theodore Iwashyna, of University of Michigan Medical School in Ann Arbor and Dr. Julia Lynch of the University of Pennsylvania in Philadelphia make the point that the numbers in a comparative study are not enough.

"An exploration of the evolution of critical care, taking into account diverse national histories and healthcare ecosystems, would help," they write.

SOURCE: American Journal of Respiratory and Critical Care Medicine, November 1, 2009.

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