Elizabeth Dzeng, MD, PhD, MPH

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The structure of institutional policies, practices, protocols, and allocation of resources can shape the culture of hospital facilities, physician behavior, and the experiences of patients, according to a recent comparative study of 3 hospitals.¹

These findings were the results of a study examining 3 hospitals in the US, seeking to explore the gap in knowledge regarding the ways in which hospital cultures are linked to institution-specific structures and with end-of-life care.

Previous research has indicated that hospital culture could be linked to the provision of non-beneficial, high-intensity treatments which are life-sustaining, so this study sought to examine this association further.² It was authored by Elizabeth Dzeng, MD, PhD, MPH, from the UCSF Division of Hospital Medicine at the University of California, San Francisco.

“The objective of this study was to elucidate our understanding of the complex, recursive relationships between hospital culture, institutional structures, and the provision of potentially nonbeneficial, high-intensity life-sustaining treatments,” Dzeng and colleagues wrote.

Background and Findings

The investigators conducted their research at 3 academic hospitals located in the states of California and Washington, with each hospital having varying intensities of end-of-life care. Their study was approved by the University of California, San Francisco institutional review board, and participants provided consent.

Their interviews were conducted with clinicians and administrators from different backgrounds and responsibilities. The research team’s study was guided by a conceptual framework based on prior literature and the authors' previous work.

The team’s collection of data involved interviews conducted by a single interviewer, both in person and through virtual video conferencing. Respondents were selected purposely and through snowball sampling until theoretical saturation ended up being reached.

An interview guide was used in the investigators’ work, which evolved throughout the study. Interviews were recorded, transcribed, and analyzed concurrently with data collection. Counterfactual data and diverse perspectives were considered to gain insights into hospital culture.

Thematic coding was performed by the research team, and disagreements were resolved through discussion. Member checking was done with clinicians, and additional interviews were also used to finalize hypotheses. Organizational similarities and differences among the hospitals were also looked at through thematic analysis.

Between December of 2018 and June of 2022, the study involved a total of 113 semistructured, in-depth interviews with clinicians and administrators in inpatient settings. The interviews were 58.4% women and 20.4% Asian, 0.9% Black, 4.4% Hispanic, 6.2% multiracial, and 61.9% White.

The investigators reported that the interviews revealed respondents at all hospitals having had a default tendency to provide high-intensity treatments, believing it to be a common practice across US facilities. The team also noted that the interviewees emphasized that concerted efforts from multiple care teams were necessary to de-escalate such treatments.

However, these types of de-escalation efforts were susceptible to interference at different stages of a patient's care by individuals or entities.

The study’s respondents discussed institution-specific practices, policies, protocols, and resources that led to a shared understanding of the importance of de-escalating non-beneficial and life-sustaining procedures. Different hospitals had varying policies and practices that either encouraged or discouraged de-escalation.

“This study illustrates how hospital culture might undermine the effect of interventions that narrowly target individuals or groups of individuals (eg, team dynamics, communications, and decision-making),” they wrote. “Consideration of hospital culture and its association with individual and clinical practice patterns should be incorporated into institutional policies, practices, and interventions.”

References

1. ^{Dzeng E, Batten JN, Dohan D, Blythe J, Ritchie CS, Curtis JR. Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers. JAMA Intern Med. Published online July 03, 2023. doi:10.1001/jamainternmed.2023.2450.}
2. ^{Curtis JR, Engelberg RA, Teno JM. Understanding variability of end-of-life care in the ICU for the elderly. Intensive Care Med. 2017;43(1):94-96. doi:10.1007/s00134-016-4340-5.}