title: Family involvement at the end-of-life and receipt of quality care.
abstract: BACKGROUND
  Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care.
  
  
  OBJECTIVE
  To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement.
  
  
  METHODS
  We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care Veterans Affairs facilities between 2010 and 2011. Outcomes included: (1) palliative care consult, (2) chaplain visit, and 3) death in an inpatient hospice or palliative care unit. We also assessed "do not resuscitate" (DNR) orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice or palliative care unit death, and DNR, we additionally adjusted for palliative care consults.
  
  
  RESULTS
  Mean (SD) age was 74 (±12) years, 98% were men, and 19% were nonwhite. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative care consult, adjusted odds ratio (AOR) 4.31 (95% CI 3.90-4.76); a chaplain visit, AOR 1.18 (95% CI 1.07-1.31); and a DNR order, AOR 4.59 (95% CI 4.08-5.16) but not more likely to die in a hospice or palliative care unit.
  
  
  CONCLUSIONS
  Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.
authors.affiliation: San Francisco VA Medical Center, University of California, San Francisco, California, USA; Division of Geriatrics, University of California, San Francisco, California, USA. Electronic address: rebecca.sudore@ucsf.edu.
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: David
authors.initials: D
authors.lastname: Casarett
authors.affiliation: Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
authors.forename: Dawn
authors.initials: D
authors.lastname: Smith
authors.affiliation: Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
authors.forename: Diane M
authors.initials: DM
authors.lastname: Richardson
authors.affiliation: School of Nursing, Philadelphia, Pennsylvania, USA; Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Ersek
mesh_terms: D000368:Aged; D002604:Chaplaincy Service, Hospital / Q000706:statistics & numerical data; D003657:Decision Making; D005190:Family; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D011787:Quality of Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D016414:Resuscitation Orders; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data
keywords: End-of-life care; communication; quality assessment; veterans