Table 1.

Variables abstracted from the medical record according to end-of-life care domains

Patient and family centered decision making

Documentation of the presence of a living will

Documentation of the presence of DPOAHC

Family’s wish to withdraw life support documented

Patient’s wish to withdraw life support documented

Patient’s opinions documented

Family present at time of death

Communication within the team and with patients and families

Documented family conference occurred in the first or last 72 hours

Prognosis discussion documented

Physician’s recommendation to withdraw life support documented

Decision to withdraw life support documented

Documentation of family discord

Documentation of discord between family and physician

Emotional and practical support for patients and families

Social Worker involved in care

Symptom management and comfort care

DNR order in place at time of death

Comfort care orders or all meds/orders discontinued at time of death

Patient died in the setting of full support

Pain assessment recorded

Shortness of breath assessment recorded

Agitation assessment recorded

Anxiety assessment recorded

Confusion assessment recorded

Presence of pain recorded

Presence of shortness of breath recorded

Presence of agitation recorded

Presence of anxiety recorded

Presence of confusion recorded

CPR performed in the last 24 hours

CPR performed in the last hour

Tube feeding orders withdrawn

TPN orders withdrawn

IVF orders withdrawn

Vasopressors withdrawn

Ventilation orders discontinued

Spiritual support for patients and families

Spiritual Care involved in care

Documentation of spirituality addressed

Abbreviations: DPOAHC: durable power of attorney for health care, DNR: do not resuscitate, CPR: cardiopulmonary resuscitation, TPN: total parenteral nutrition, IVF: intravenous fluids