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 < or = .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.