Patterns of Life-Sustaining Treatment Preferences Among Seriously Ill Veterans

Area of Science:

• Gerontology
• Health Services Research
• Clinical Informatics

Background:

• Advance care planning and documenting life-sustaining treatment (LST) preferences are crucial for patient-centered care.
• Patient preference stability for LSTs, particularly among community-dwelling older adults, requires further investigation.
• The Department of Veterans Affairs (VA) Life-Sustaining Treatment Decisions Initiative offers a valuable dataset for studying preference trajectories in seriously ill Veterans.

Purpose of the Study:

• To identify distinct cardiopulmonary resuscitation (CPR) preference trajectories among Veterans.
• To characterize Veterans within each identified CPR preference trajectory.
• To examine the associations between demographic and clinical factors and CPR preference trajectory membership.

Main Methods:

• A longitudinal observational analysis of VA Corporate Data Warehouse data was conducted.
• 161,725 Veterans with completed LST templates as of October 1, 2019, were included.
• CPR preference (full code vs. do-not-resuscitate [DNR]) stability was analyzed over 39 months using sequence analysis, and multinomial logistic regression identified associated factors.

Main Results:

• Four CPR preference trajectories were identified: persistent DNR (39.8%), fluctuating with early mortality (8.7%), fluctuating with later mortality (7.3%), and persistent full code (44.3%).
• Older Veterans were more likely to maintain DNR preferences, while younger Veterans preferred full code.
• Higher comorbidity burden, heart failure, and increased hospitalization rates were linked to fluctuating preferences; dementia was associated with persistent DNR.

Conclusions:

• CPR preference trajectories among Veterans are complex and dynamic, necessitating personalized advance care planning.
• Healthcare providers should consider dynamic clinical factors and use hospitalizations as opportunities for care discussions.
• Culturally sensitive communication is vital for aligning treatment preferences with evolving patient goals and values.