Patterns of life-sustaining treatment preferences among seriously ill Veterans

Abstract: Background: Goals of care conversations and documentation of life-sustaining treatment (LST) preferences through durable, portable medical orders are critical for aligning care with patient values. The stability of patient preferences over time remains uncertain, particularly among community-dwelling adults. The Department of Veterans Affairs Life-Sustaining Treatment Decisions Initiative provides a unique opportunity to examine preference trajectories among seriously ill Veterans using longitudinal real-world data. This analysis aimed to: identify cardiopulmonary resuscitation (CPR) preference trajectories, describe Veterans' characteristics by trajectory, and examine associations between trajectories and demographic/clinical factors. Methods: This longitudinal observational analysis used VA Corporate Data Warehouse data to identify the population of Veterans with completed LST templates as of October 1, 2019 (N = 161,725). CPR preference (full code or do-not-resuscitate [DNR]) over 39 months was analyzed for stability using sequence analysis, and CPR preference trajectories were identified. Veterans' characteristics were compared across trajectories, and multinomial logistic regression was used to assess associations with trajectory membership. Results: Four CPR preference trajectories were identified: (1) persistent preference for DNR (39.8%), (2) code status fluctuation with early mortality (8.7%), (3) code status fluctuation with later mortality (7.3%), and (4) persistent preference for full code (44.3%). Older Veterans were more likely to persist in DNR preferences, while younger Veterans were in full code. Veterans having higher baseline comorbidities, chronic conditions such as heart failure, and higher hospitalization rates were at greater risk of having fluctuating preferences. Those with dementia had a greater likelihood of persistent DNR. Conclusions: This analysis provides critical insights into the complexity of CPR preference trajectories among Veterans, highlighting the need for nuanced, patient-centered approaches to advance care planning. By addressing dynamic clinical factors, leveraging hospitalizations as strategic opportunities, and incorporating culturally sensitive communication, healthcare providers can improve the alignment of treatment preferences with patients' evolving goals and values.