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 ICU.Objective-To identify chart-based markers that could be used as measures for improving the quality of end-of-life care.Design-A multi-center study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hours of being transferred from an ICU. Setting-ICUs at ten hospitals in the Northwest US.Patients-356 patients who died in the ICU or within 24 hours of transfer from an ICU.Measurements-1) the 22-item family-assessed Quality of Dying and Death (QODD-22); 2) 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 tests, Kruskal Wallis tests, or Spearman correlation coefficients as appropriate.Results-Higher QODD-22 scores were associated with documentation of a living will (p = 0.03), absence of CPR performed in the last hour of life (p = 0.01), withdrawal of tube feeding (p = 0.04), family presence at time of death (p=0.02), and discussion of the patient's wish to withdraw life support during a family conference (p<0.001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p≤0.05).Conclusions-We identified chart-based variables associated with higher QODD scores. These could serve as targets for measuring and improving the quality of end-of-life care in the ICU. MeSH Headings

These findings suggest that for patients dying in the ICU, clinicians should assess each family's spiritual needs and consult a spiritual advisor if desired by the family. Further research is needed to develop a comprehensive approach to ICU care that meets not only physical and psychosocial but also spiritual needs of patients and their families.