Documentation of Life-Sustaining Treatment Preferences in a National Cohort of Veteran Decedents.
Academic Article
Overview
abstract
BACKGROUND: Discussing and documenting preferences for life-sustaining treatment (LST) is critical for patient-centered care, yet many patients do not have documented plans when a medical crisis arises. In 2018, the Veterans Health Administration (VHA) introduced a standardized electronic health record (EHR) note to facilitate LST preference documentation for high-risk Veterans. OBJECTIVE: Assess patterns and factors associated with LST note completion. DESIGN: Retrospective cohort study. PATIENTS: National sample of 22,919 Veterans aged ≥ 60 years who died in 2021 and received VHA care in the 2 years before death. MAIN MEASURES: LST note completion was defined as having EHR documentation of all required note questions. We obtained Veteran sociodemographic, clinical, and care utilization factors over the 2 years before death using VHA and Medicare claims data. KEY RESULTS: Of the cohort, 6573 (28.7%) had an LST note documented ≥ 1 time. First LST documentation occurred a median of 362 days before death; a surrogate consented to 2209 (33.6%) of the most recent completions. Completion was markedly higher in those admitted to high-intensity VHA services (i.e., hospital, nursing home, or home-based primary care), so we estimated logistic regression models stratified by the presence (n = 8485) or absence (n = 14,434) of any high-intensity VHA care. In adjusted analyses of both strata, greater comorbidity, hospice use, and more primary care visits were associated with higher odds of LST note completion (p < 0.001). Among decedents without high-intensity VHA care, being unmarried with a child as next of kin and more VA financial benefits were also associated with higher odds of completion (p < 0.001). CONCLUSIONS: LST note completion occurred in a minority of decedents, was strongly tied to high-intensity VHA service utilization, and was often done by a surrogate. Opportunities may exist to improve documentation of patient preferences in outpatient settings farther in advance of health declines.
