End-of-Life Care Quality Differs by Diagnosis, Study Shows

Veronica Hackethal, MD

June 29, 2016

Patients with cancer and dementia have significantly better end-of-life quality of care than those with end-stage renal disease (ESRD), cardiopulmonary failure, or frailty, according to a study of family-reported data published online June 26 in JAMA Internal Medicine.

The findings may be the result of higher rates of palliative care consultations, do-not-resuscitate orders, and fewer deaths in the intensive care unit among patients with cancer and dementia compared with among patients with other diagnoses.

"These findings suggest a need for greater attention to diagnosis-related disparities in the quality of end-of-life care," write Melissa W. Wachterman, MD, MPH, from the Veterans Administration (VA) Boston Healthcare System and Brigham and Women's Hospital, Boston, Massachusetts, and colleagues.

The study represents the first and most comprehensive evaluation of the quality of end-of-life care across several diagnoses, according to the authors.

Efforts to improve the quality of end-of-life care have focused on patients with cancer, even though most Americans die from other illnesses. The aging US population, however, has drawn attention to the need for high-quality end-of-life care among all patients.

In the study, Dr Wachterman and colleagues reviewed medical records and used data from the VA's Bereaved Family Survey, which is intended to assess families' experiences with the quality of care of patients who have died within the VA system.

The study took place in 146 VA facilities nationwide and included 57,753 inpatients who died between October 2009 and September 2012. The researchers categorized diagnoses as follows: ESRD, cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions.

The investigators looked at palliative care consultation and do-not-resuscitate orders, which have been associated with high-quality end-of-life care. They also looked at death in the hospital, palliative care unit, or intensive care unit, the last of which has been linked to worse family-reported quality of end-of-life care.

They found that rates of palliative care consultations were significantly higher among patients with cancer (adjusted proportion, 73.5%) and dementia (61.4%) compared with those with ESRD (50.4%), cardiopulmonary failure (46.7%), or frailty (43.7%; P < .001).

Patients with ESRD, cardiopulmonary failure, or frailty were much more likely to die in an intensive care unit (32.3%, 34.1%, and 35.2%, respectively) than were patients with cancer or dementia (13.4% and 8.9%, respectively; P < .001).

Similarly, patients with ESRD, cardiopulmonary failure, or frailty were much less likely to die with hospice care (24.3%, 22.9%, and 20.3%, respectively) than were patients with cancer or dementia (42.9% and 32.3%, respectively).

Patients with cancer and dementia also had higher rates of do-not-resuscitate orders (95.3% and 93.5%, respectively) compared with those with ESRD (87.0%), cardiopulmonary failure (86.3%), and frailty (88.6%).

Families (n = 34,005) of patients with cancer or dementia reported similar rates of excellent-quality end-of-life care (59.2% and 59.3%, respectively; P = .61). However, these rates were significantly lower for families of patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02).

Factors independently linked to family-reported excellent end-of-life care included palliative care consultations, setting of death, and code status.

The study could not fully evaluate end-of-life care for patients with multiple illnesses, which may be different than for those with one condition. Other limitations include the challenge of defining frailty using administrative data and generalizability outside the VA system.

"Increasing access to palliative care and increasing the rates of goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the quality of end-of-life care for Americans dying with these conditions," the authors conclude.

In an invited commentary, Stacy Fischer, MD, from the University of Colorado School of Medicine in Aurora, and colleagues highlighted the importance of early access to palliative care while mentioning that workforce shortages limit access. Expanding the palliative care workforce is "critical," they emphasize. More research is needed to identify which services and interventions are actually helpful, and how primary care teams can implement them.

"Not every patient needs a palliative care consultation with a specialist palliative care physician, nurse, and social worker," they write, "Understanding which patients need which components and expanding primary palliative care may be the only way to meet the growing need for patients with advanced progressive medical illnesses."

The study was supported the National Palliative Care Research Center, the National Institute on Aging, and the Department of Veterans Affairs, Veterans Health Administration. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online June 26, 2016. Article full text, Commentary full text

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