Wednesday, 9 April 2008

Critical Care Medicine. 36(4) April 2008

Mularski, Richard A. MD, MSHS, MCR
The Center for Health Research, Kaiser Permanente Northwest, Pulmonary & Critical Care Medicine, Northwest Permanente, PC, Department of Medicine, Oregon Health & Science University, Portland, OR
The search for a good death-Are there quality insights accessible from medical records? *.[Editorial]
Critical Care Medicine. 36(4):1372-1373, April 2008.

Glavan, Bradford J. MD; Engelberg, Ruth A. PhD; Downey, Lois MA; Curtis, J Randall MD, MPH; Institution
From the Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Washington, Seattle, WA.
Using the medical record to evaluate the quality of end-of-life care in the intensive care unit *.[Article]
Critical Care Medicine. 36(4):1138-1146, April 2008.
Rationale: We investigated whether proposed "quality markers" within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU).Objective: To identify chart-based markers that could be used as measures for improving the quality of end-of-life care.Design: A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU.Setting: ICUs at ten hospitals in the northwest United States.Patients: Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU.Measurements: The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1).Analysis: The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate.Results: Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p <= .05).Conclusions: We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

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