For a study, researchers sought to learn how hospital cultures affect the intensity of end-of-life (EOL) care. Four university hospitals in California and Washington participated in comparative ethnographic research. The Dartmouth Atlas was used to choose hospitals based on variations in the intensity of EOL treatment (high, medium, and low). Between December 2018 and December 2020, semi-structured, in-depth interviews were performed with 112 doctors, hospital workers, and administrators. Data were deductively and inductively evaluated using theme analysis in an iterative, team-based coding approach.

All four locations had a universal default of high-intensity care; respondents perceived this as the standard in American healthcare. Respondents were asked to utilize active and aggressive attempts to de-escalate high-intensity EOL care, even if treatments did not align with patients’ goals. Attempts to de-escalate high-intensity, goal-discordant treatment were resisted several times along a patient’s care trajectory, according to respondents in high-intensity hospitals. De-escalation was aided by hospital-specific resources, policies, and procedures in hospitals with a culture that encouraged low-intensity EOL treatment. A core element of distinct cultures of intensities of care is the tendency of a hospital’s environment to either promote or hinder clinician attempts to de-escalate high-intensity EOL treatment. Policies, procedures, and resources that either allow or discourage resistance to a prevalent culture of high-intensity treatment in American medicine impact the intensity of EOL care.