Honoring Veterans’ Preferences: The Association between Comfort Care Goals and Care Received at the End of Life

Abstract Context As part of its Life Sustaining Treatment (LST) Decisions Initiative (LSTDI) the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events. Objectives To evaluate whether goals of “to be comfortable” were associated with greater palliative care (PC) use and lesser acute care use. Methods We identified Veterans with VA inpatient or nursing home stays overlapping July 2018--January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a “to be comfortable” goal. Using VA and Medicare data we determined PC use (consultations and hospice) and hospital, intensive care unit (ICU) and emergency department (ED) use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest. Results Sixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort-care goals received hospice and 57% PC consultations (versus 57% and 46% [respectively] for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, ICU and ED use near the end of life. In the last 30 days of life Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized. Conclusion Findings support the VA’s commitment to honoring of Veterans’ preferences post introduction of its LSTDI. Key Message This study examines the association between comfort care goals and care near the end of life for Veteran decedents cared for after the Veterans Health Administration’s Introduction of its Life-Sustaining Treatment Decisions Initiative. Findings show Veteran decedents with comfort care goals received care that appears concordant with their preferences.