• Lena K Makaroun, Joan M Teno, Vicki A Freedman, Judith D Kasper, Pedro Gozalo, and Vincent Mor.
• Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, Seattle, Washington.
• J Am Geriatr Soc. 2018 Sep 1; 66 (9): 1730-1736.

ObjectivesTo examine associations between healthcare transitions at the end of life (EOL; late transitions) and bereaved family members' and friends' assessment of EOL quality of care (QOC).DesignNational Health and Aging Trends Study (NHATS), a prospective cohort of Medicare enrollees aged 65 and older.SettingUnited States, all sites of death.ParticipantsFamily members and close friends of decedents from NHATS Rounds 2 through 6 (N=1,653; weighted 6.0 million Medicare deaths).MeasurementsMultivariable logistic regression with survey weights was used to examine the association between having a late transition and reports of perceived unmet needs for symptom management, spiritual support, concerns with communication, and overall QOC.ResultsSeventeen percent of decedents had a late transition. Bereaved respondents for decedents experiencing late transitions were more likely to report that the decedent was treated without respect (21.3% vs 15.6%; adjusted odds ratio (AOR)=1.59, 95% confidence interval (CI)=1.09-2.33), had more unmet needs for spiritual support (67.4% v 55.2%; AOR=1.48, 95% CI=1.03-2.13), and were more likely to report they were not kept informed about the person's condition (31.0% vs 20.9%; AOR=1.54, 95% CI=1.07-2.23). Bereaved respondents were less likely to rate QOC as excellent when there was a late transition (43.6% vs 48.2%; AOR=0.79, 95% CI=0.58-1.06). Subgroup analyses of those experiencing a transition between a nursing home and hospital (13% of all late transitions) revealed such transitions to be associated with even worse QOC.ConclusionTransitions in the last 3 days of life are associated with more unmet needs, higher rate of concerns, and lower rating of QOC than when such late transitions are absent, especially when that transition is between a nursing home and hospital.© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

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