Levy CR (Denver REAP), Williams L
1) Describe characteristics of veterans living in a Community Living Centers (CLC) prior to death, and 2) to determine factors that predict site of death (hospital vs. CLC) among veterans living in a CLC.
The Beneficiary Identification Records Locator Subsystem (BIRLS) was used to identify veterans with a date of death in FY2005. Minimum Data Set data were extracted for all decedents and site of death was identified using the Extended Care Main File. Two group comparisons were performed followed by multivariate regression analysis to determine factors predictive of hospital as a site of death.
Among CLC residents, 86.2% (N = 6,096) died in a CLC and 13.8% (N = 978) were transferred to and subsequently died in a VA hospital. Of decedents in a CLC, 38.1% (N = 2,401) were in a designated hospice bed section versus 2.1% (N = 21) of veterans dying in a hospital. Daily pain was experienced by 43.3% (N = 3,063) of CLC decedents, and of those with pain, 77.5% (3,597) reported the pain as moderate or excruciating. 66.9% (4,078) veterans dying in a CLC had a do not resuscitate (DNR) order compared to 32.6% (N = 313) of veterans dying is a hospital (p < 0.0001). Advance directives were absent for nearly half (46.7%, N = 449) of hospital decedents compared to 19.2% (N = 1,136) of CLC decedents (p < 0.001). In multivariate analyses, death in a hospital was more likely for veterans who did not have a DNR order (OR 1.5, 95% CI 1.2-2.0) and who were not in a hospice bed designation (OR 8.4, 95% CI 4.9-14.8). Veterans dying in a VA hospital were more likely to have multiple hospitalizations in the year prior to death (OR 1.2, 95% CI 1.1-1.3) and take greater than 11 medications (OR 1.4, 95% CI 1.2-1.7).
Prevalence of moderate-severe pain is high among CLC residents. Hospice designation for CLC decedents exceeds hospice usage reported in community-based nursing homes. Absence of documented care goals is associated with a higher likelihood of hospital death, as are repeated hospitalizations and polypharmacy.
High prevalence of pain among veterans in hospice beds is concerning, as are low advance directive completion rates in this vulnerable population.