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Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes
Author(s) -
Cohen Andrew B.,
Han Ling,
OʼLeary John R.,
Fried Terri R.
Publication year - 2021
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.16900
Subject(s) - medicine , odds ratio , intensive care unit , dementia , mechanical ventilation , cardiopulmonary resuscitation , confidence interval , end of life care , emergency medicine , advance care planning , minimum data set , retrospective cohort study , resuscitation , nursing homes , nursing , intensive care medicine , palliative care , disease
BACKGROUND/OBJECTIVES Experts have suggested that patients represented by professional guardians receive higher intensity end‐of‐life treatment than other patients, but there is little corresponding empirical data. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non‐VA). MEASUREMENTS Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home‐to‐hospital transfers in the last 90 days of life, and in‐hospital death. RESULTS ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89–1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end‐of‐life hospitalizations, and in‐hospital death were more common among matched controls. CONCLUSION Rates of high‐intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high‐intensity treatment occurred more frequently than expected among patients without guardians.