There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs).

To develop hypotheses regarding medical decision-making factors underlying this variation.

High-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis.

2 AMCs in the same state and health care system with disparate EOL ICU use.

Hospital-based physicians responsible for ICU admission decisions.

Treatment plan, prognosis, diagnosis, qualitative case perceptions and clinical reasoning.

Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a DNR order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient’s known metastatic gastric cancer in the context of norms of oncologists’ avoiding code status discussions.

In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.