Using the medical record to evaluate the quality of end-of-life care in the intensive care unit

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.