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Levy C, Esmaeili A, Smith D, Hogikyan RV, Periyakoil VS, Carpenter JG, Sales A, Phibbs CS, Murray A, Ersek M. Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes. J Am Geriatr Soc 2024. [PMID: 38970392 DOI: 10.1111/jgs.19050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. METHODS Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. RESULTS LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. CONCLUSIONS Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aryan Esmaeili
- Department of Veterans Affairs, Palo Alto, California, USA
| | - Dawn Smith
- Veteran Experience Center, Department of Veterans Affairs, Philadelphia, Pennsylvania, USA
| | - Robert V Hogikyan
- Department of Veterans Affairs, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Joan G Carpenter
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Anne Sales
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Ciaran S Phibbs
- Department of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Andrew Murray
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Veteran Experience Center, Department of Veterans Affairs, Philadelphia, Pennsylvania, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Wen FH, Chou WC, Huang CC, Hu TH, Chuang LP, Tang ST. Factors Associated With Quality-of-Dying-and-Death Classes Among Critically Ill Patients. JAMA Netw Open 2024; 7:e2420388. [PMID: 38949808 PMCID: PMC11217872 DOI: 10.1001/jamanetworkopen.2024.20388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/05/2024] [Indexed: 07/02/2024] Open
Abstract
Importance Improving end-of-life care in the intensive care unit (ICU) is a priority, but clinically modifiable factors of quality of dying and death (QODD) are seldom identified. Objectives To comprehensively identify factors associated with QODD classes of dying ICU patients, emphasizing clinically modifiable factors based on the integrative framework of factors associated with for bereavement outcomes. Design, Setting, and Participants This observational cohort study was conducted at medical ICUs of 2 Taiwanese medical centers from January 2018 to March 2020 with follow-up through December 2022. Eligible participants included primary family surrogates responsible for decision making for critically ill ICU patients at high risk of death (Acute Physiology and Chronic Health Evaluation II score >20) but who survived more than 3 days after ICU admission. Data analysis was conducted from July to September 2023. Main Outcomes and Measures QODD was measured by the 23-item ICU-QODD questionnaire. Factors associated with patient membership in 4 previously determined QODD classes (high, moderate, poor to uncertain, and worst) were examined using a 3-step approach for latent class modeling with the high QODD class as the reference category. Results A total of 309 family surrogates (mean [SD] age, 49.83 [12.55] years; 184 women [59.5%] and 125 men [40.5%]) were included in the study. Of all surrogates, 91 (29.4%) were the patients' spouse and 66 (53.7%) were the patients' adult child. Patient demographics were not associated with QODD class. Two family demographics (age and gender), relationship with the patient (spousal or adult-child), and length of ICU stay were associated with QODD classes. Patients of surrogates perceiving greater social support were less likely to be in the poor to uncertain (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94) and worst (aOR, 0.92; 95% CI, 0.87-0.96) QODD classes. Family meetings were associated with the poor to uncertain QODD class (aOR, 8.61; 95% CI, 2.49-29.74) and worst QODD class (aOR, 7.28; 95% CI, 1.37-38.71). Death with cardiopulmonary resuscitation was associated with the worst QODD class (aOR, 7.51; 95% CI, 1.12-50.25). Family presence at patient death was uniformly negatively associated with the moderate QODD class (aOR, 0.16; 95% CI, 0.05-0.54), poor to uncertain QODD class (aOR, 0.21; 95% CI, 0.05-0.82), and worst QODD class (aOR, 0.08; 95% CI, 0.02-0.38). Higher family satisfaction with ICU care was negatively associated with the poor to uncertain QODD class (aOR, 0.93; 95% CI, 0.87-0.98) and worst QODD class (aOR, 0.86; 95% CI, 0.81-0.92). Conclusions and Relevance In this cohort study of critically ill patients and their family surrogates, modifiable end-of-life ICU-care characteristics played a more significant role in associations with patient QODD class than did immutable family demographics, preexisting family health conditions, patient demographics, and patient clinical characteristics, thereby illuminating actionable opportunities to improve end-of-life ICU care.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
- Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, R.O.C
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan, R.O.C
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Wen FH, Chiang MC, Huang CC, Hu TH, Chou WC, Chuang LP, Tang ST. Quality of dying and death in intensive care units: family satisfaction. BMJ Support Palliat Care 2024; 13:e1217-e1227. [PMID: 36593102 DOI: 10.1136/spcare-2022-003950] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This cohort study identified patterns/classes of surrogates' assessment of their relative's quality of dying and death (QODD) and to evaluate their associations with family satisfaction with intensive care unit (ICU) care. METHODS We identified QODD classes through latent class analysis of the frequency component of the QODD questionnaire and examined their differences in summary questions on the QODD and scores of the Family Satisfaction in the ICU questionnaire among 309 bereaved surrogates of ICU decedents. RESULTS Four distinct classes (prevalence) were identified: high (41.3%), moderate (20.1%), poor-to-uncertain (21.7%) and worst (16.9%) QODD classes. Characteristics differentiate these QODD classes including physical symptom control, emotional preparedness for death, and amount of life-sustaining treatments (LSTs) received. Patients in the high QODD class had optimal physical symptom control, moderate-to-sufficient emotional preparedness for death and few LSTs received. Patients in the moderate QODD class had adequate physical symptom control, moderate-to-sufficient emotional preparedness for death and the least LSTs received. Patients in the poor-to-uncertain QODD class had inadequate physical symptom control, insufficient-uncertain emotional preparedness for death and some LSTs received. Patients in the worst QODD class had poorest physical symptom control, insufficient-to-moderate emotional preparedness for death and substantial LSTs received. Bereaved surrogates in the worst QODD class scored significantly lower in evaluations of the patient's overall QODD, and satisfaction with ICU care and decision-making process than those in the other classes. CONCLUSIONS The identified distinct QODD classes offer potential actionable direction for improving quality of end-of-life ICU care.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University - Downtown Campus, Taipei, Taiwan
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Chung-Chi Huang
- Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Hui Hu
- Department of Internal Medicine, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Pang Chuang
- Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Siew Tzuh Tang
- School of Nursing, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Division of Hematology-Oncology, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
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Chiang MC, Huang CC, Hu TH, Chou WC, Chuang LP, Tang ST. Factors associated with bereaved family surrogates' satisfaction with end-of-life care in intensive care units. Intensive Crit Care Nurs 2022; 71:103243. [PMID: 35396097 DOI: 10.1016/j.iccn.2022.103243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Family satisfaction with end-of-life care in the intensive care unit constitutes an important outcome for evaluating end-of-life care quality. Research on this topic focuses on linking end-of-life care processes to family-surrogate satisfaction with the patient's end-of-life care but has seldom examined patient- and family-surrogate-based factors. We aimed to comprehensively and simultaneously examine factors facilitating or deterring family satisfaction with end-of-life care in the intensive care unit from patient- and family-surrogate perspectives. METHODS For this secondary-analysis study, 278 Taiwanese family surrogates were surveyed one-month post-patient death using the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU), which measures care and decision-making. Associations between family satisfaction with end-of-life care and patient and family characteristics, patient disease severity, and length of intensive care stay were examined by multivariate, multilevel linear regression models. RESULTS Female family surrogates were more satisfied with patients' end-of-life care than male family surrogates when patients had a higher APACHE II but a lower SOFA score. Adult-child surrogates had lower FS-ICU Care scores than other family surrogates. Higher satisfaction with ICU decision-making was associated with patients' higher APACHE II but lower SOFA scores, longer stay and family socio-demographics, including being unmarried, educational attainment above junior high school and reported financial sufficiency to make ends meet. CONCLUSION Patient disease severity and family-surrogate characteristics are significantly associated with surrogates' satisfaction with patients' end-of-life care in the intensive care unit. Specific interventions should be tailored to the needs of high-risk family surrogates to increase their satisfaction with this care.
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Affiliation(s)
- Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, ROC
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC
| | - Siew Tzuh Tang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, ROC.
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