Late Transitions and Bereaved Family Member Perceptions of Quality of End-of-Life Care

Abstract

Background/Objective: Health care transitions in the last three days of life have increased in the United States. We aimed to examine the impact of transitions in the last three days of life on bereaved family members' and friends' assessment of the quality of end-of-life care. Design: National Health and Aging Trends Study (NHATS), a prospective cohort of Medicare enrollees age ≥ 65. Setting: United States, all sites of death. Participants: Family members and close friends of decedents from NHATS rounds 2-6 (N=1,653; weighted 6.0 million Medicare deaths). Exposure: Medicare decedents' experiencing a transition between any location and a healthcare institution in the last three days of life. Measurements: Multivariable logistic regression with survey weights examined the association between having a late transition and reports of perceived unmet needs for symptom management, spiritual support, concerns with communication, and overall care quality (QOC). Results: Seventeen percent of decedents experienced a late transition. Bereaved respondents for decedents experiencing late transitions were more likely to report that their loved one was treated without respect (adjusted odds ratio (AOR) 1.59, 95% confidence interval (CI): 1.09 - 2.33), had more unmet needs for spiritual support (AOR 1.48, 95% CI: 1.03 - 2.13), and were more likely to report they were not kept informed about patients' condition (AOR 1.54, 95% CI: 1.07 - 2.23). Bereaved respondents were less likely to rate QOC as excellent when there was a late transition (AOR 0.79, 95% CI: 0.58 - 1.06). Sub-group analyses of those experiencing a transition between a nursing home and hospital (13% of all late transitions) revealed such transitions to be associated with even worse QOC. Conclusion: Transitions in the last three days of life are associated with more unmet needs, higher rate of concerns, and lower rating of quality of care, especially when that transition is between a nursing home and hospital.