Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life

Context: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care. Objective: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models. Design: Ethnographic study of three critical care units. Setting: University hospitals in the United States and New Zealand. Subjects: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends. Measurements and Main Results: Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families. Conclusions: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.