Inferior VA End-of-Life Care Reported for Some Noncancer Conditions

Those Veterans More Likely to Die in ICU, Have No DNR Orders

By Brenda L. Mooney

Durham, NC, VAMC volunteer Alan Makhoul visits with Army Veteran Joe Bradford at the facility’s Hero’s Way Hospice Unit. Photo courtesy of Durham VAMC.

Durham, NC, VAMC volunteer Alan Makhoul visits with Army Veteran Joe Bradford at the facility’s Hero’s Way Hospice Unit. Photo courtesy of Durham VAMC.

BOSTON—Although most patients in the United States die of another condition, cancer is the focus of most end-of-life care studies.

The result, according to new VA-led research, is that families reported better quality of end-of-life care for veterans with cancer—and for dementia—than for those with end-stage renal disease (ESRD), cardiopulmonary failure or frailty.

The likely reasons? Patients with cancer or dementia had higher rates of palliative care consultations and do-not-resuscitate orders, and fewer died in hospital intensive care units, according to the report published online by JAMA Internal Medicine and to coincide with a presentation at AcademyHealth’s Annual Research Meeting in June.1

The study looked at patients who died at 146 inpatient facilities within the VA healthcare system and was led by researchers from the Boston VAMC.

“We need to broaden our attention to improve the quality of end-of-life care for all patients, not just those with cancer or dementia,” said lead author Melissa Wachterman, MD, MPH, MSc, who in addition to her VA role is at Harvard Medical School and Dana-Farber/Brigham and Women’s Cancer Center. “Our study shows that, while there is room for improvement in the quality of end-of-life care for all patients, this is particularly true for patients dying of heart failure, chronic lung disease and renal failure.”

Medical records and family surveys were examined for more than 34,000 patients who died at the VA between 2009 and 2012. Veterans with end-stage renal disease, cardiopulmonary failure —congestive heart failure or chronic obstructive pulmonary disease —and frailty were far less likely to receive palliative care consultations than patients with cancer or dementia.

In fact, one-third of those patients died in the intensive care unit, more than twice the rates for those with cancer or dementia. Those veterans also were less likely to have do-not-resuscitate orders.

On the other hand, death in a hospice unit—the inpatient setting with the highest level of family-reported quality —was more common among patients with cancer and those with dementia than among those with end-organ failure or frailty.

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