Do-not-hospitalize Research Articles

Advance Directives Change Frequently in Nursing Home Residents

ObjectivesTo describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs). DesignA retrospective cohort study. Setting and ParticipantsAdmissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017. MethodsResidents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables. ResultsA total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates. Conclusions and ImplicationsMeasuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.

Education, Policy, and Advocacy in Predicting Use of Do-Not-Hospitalize Orders in Skilled Nursing Facilities.

Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers (N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families (p < 0.01 for each variable). [Journal of Gerontological Nursing, 48(11), 45-52.].

Reasons for Discordance Between Life-Sustaining Treatment Preferences and Medical Orders in Nursing Facilities Without POLST.

Life-sustaining treatment (LST) orders are important communication tools used to ensure preference-concordant care at the end of life. Recent studies reveal concerning rates of discordance between current preferences and documented LST orders, especially in nursing facilities without POLST. Reasons for discordance in facilities using POLST have been explored, however the majority of nursing facilities in the United States do not yet use the POLST form. Qualitative descriptive study using constant comparative analysis. Nursing facilities in Indiana (n = 6) not using POLST. Residents (n = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders. Do not resuscitate, do not hospitalize (DNH), and do not intubate (DNI) orders were extracted from medical charts. Current preferences were elicited using the Respecting Choices Advanced Steps model. A semi-structured interview guide was used to explore reasons for discordance between current preferences and LST orders. Reasons for discordance included: (1) inadequate information about the range of available LST options, what each involves, and how to formally communicate preferences; (2) no previous discussion with facility staff; (3) no documentation of previously expressed preferences; and (4) family involvement. Reasons for discordance between expressed preferences and LST orders suggest that in facilities without a uniform and systematic LST order documentation strategy like POLST, these conversations may not occur and/or be documented. Staff should be aware that residents and surrogates may have preferences about LSTs that require strategic solicitation and documentation.

Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

BackgroundResidents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes.MethodsIn this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015.ResultsWe report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively.ConclusionEven though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

An advance care planning long-term care initiative in response to COVID-19.

ObjectiveDescribe a systematic approach to address advance care planning (ACP) during a COVID‐19 outbreak and its impact on the incidence of new do‐not‐hospitalize (DNH) directives among long‐term care (LTC) residents.DesignProspective quality improvement initiative.SettingTwo long‐term chronic care campuses within a large academic healthcare organization.ParticipantsLTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020.InterventionUsing a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID‐19 focused ACP discussions. Residents without DNH directives with COVID‐19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly.MeasurementsResidents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020.ResultsAt baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID‐19 from April 2, 2020 to May 21, 2020. During follow‐up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID‐19, and 29/124 (23%) died.ConclusionsThere was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID‐19 pandemic through a systematic ACP initiative which utilized real‐time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.

Goals of Care During the COVID-19 Pandemic: Implementing DNI, DNR, and DNH Orders in a Skilled Nursing Facility

Knowledge of patient treatment preferences concerning resuscitation, intubation, and hospitalization are critical as hospitals and skilled nursing facilities (SNFs) admit older COVID-19 patients facing uncertain disease trajectories that could turn fatal within days. The present study examined the number of Do Not Intubate (DNI), Do Not Resuscitate (DNR), and Do Not Hospitalize (DNH) orders before and after patients were diagnosed with COVID-19 in a New York City SNF, as well as demographic variables related to order implementation. Subjects were 150 SNF patients who tested positive for COVID-19 between March and May 2020. All data, including demographic information, medical orders, and goals of care (GOC) discussions were obtained from the SNF’s electronic medical records. Bivariate correlations and Chi-square analyses were conducted. Patient ages ranged from 42 to 103 years (Mean=79.82, SD=11.78). Ninety-six (64%) patients were female and 48 (32%) were White, 46 (31%) Black, 22 (15%) Hispanic, 2 (1%) Asian, and 32 (21%) unknown. Most (118, 79%) reported English as their primary language. SNF length of stay (LOS) ranged from 6 days to 11 years (Mean=842.67 days, SD=931.18). One hundred and eleven (74%) patients were long-term care (LTC) and 39 (26%) were post-acute (LOS <100 days). Fifty three (35%) patients were enrolled in Optum, a service providing added specialized care by nurse practitioners (NPs). Optum NPs initiate GOC discussions routinely and when life-threatening changes in condition occur. Pre-COVID-19, 79 (53%) patients had DNR orders, 76 (51%) DNI, and 24 (16%) DNH. Overall, 69 (46%) patients did not have any DNI, DNR, or DNH orders. After COVID-19 onset, 99 (66%) of the 150 patients/families had GOC and treatment option discussions with their clinicians. Following these conversations, 96 additional orders (22 DNIs, 22 DNRs, and 52 DNHs) were placed for 57 (58%) patients. Relatedly, the number of patients lacking any medical orders decreased to 47 (31%). Older age (r =.227, p <.01), LTC (X2=7.1, p < .05), and Optum enrollment (X2=15.07, p <.01) were associated with additional medical orders after a COVID-19 diagnosis. No relationship with changes in medical orders were found for gender, race, and primary language. After COVID-19 diagnoses, GOC conversations resulted in a substantial increase in DNR, DNI, and DNH orders. Unsurprisingly, older LTC residents were more likely to implement new DNR, DNI, and DNH orders. As Optum NPs routinely discuss GOC with patients/families, decision-making during critical times may be facilitated.

Changes in Advance Care Planning for Nursing Home Residents During the COVID-19 Pandemic

ObjectiveDescribe the care preference changes among nursing home residents receiving proactive Advance Care Planning (ACP) conversations from health care practitioners during the COVID-19 pandemic. DesignRetrospective chart review. Setting and ParticipantsNursing home residents (n = 963) or their surrogate decision makers had at least 1 ACP conversation with a primary health care practitioner between April 1, 2020, and May 30, 2020, and made decisions of any changes in code status and hospitalization preferences. MethodsHealth care practitioners conducted ACP conversations proactively with residents or their surrogate decision makers at 15 nursing homes in a metropolitan area of the southwestern United States between April 1, 2020, and May 30, 2020. ACP conversations reviewed code status and goals of care including Do Not Hospitalize (DNH) care preference. Resident age, gender, code status, and DNH choice before and after the ACP conversations were documented. Descriptive data analyses identified significant changes in resident care preferences before and after ACP conversations. ResultsBefore the most recent ACP discussion, 361 residents were full code status and the rest were Out of Hospital Do Not Resuscitate (DNR). Of the individuals with Out of Hospital DNR, 188 residents also chose DNH. After the ACP conversation, 88 residents opted to change from full code status to Out of Hospital DNR, thereby increasing the percentage of residents with Out of Hospital DNR from 63% to 72%. Almost half of the residents decided to keep or change to the DNH care option after the ACP conversation. Conclusion and ImplicationsProactive ACP conversations during COVID-19 increased DNH from less than a quarter to almost half among the nursing home residents. Out of Hospital DNR increased by 9%. It is important for all health care practitioners to proactively review ACP with nursing home residents and their surrogate decision makers during a pandemic, thereby ensuring care consistent with personal goals of care and avoiding unnecessary hospitalizations.

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre.

BackgroundAdvance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice.MethodsThis was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis.ResultsIn 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively.ConclusionsClinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

Do-Not-Resuscitate and Do-Not-Hospitalize Orders in Nursing Homes: Who Gets Them and Do They Make a Difference?

ObjectivesTo describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival. DesignA retrospective cohort study. Setting and participantsAdmissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390). MeasuresWe examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics. ResultsUpon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital. Conclusions and implicationsThis study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.

An Advance Care Planning Video Decision Support Tool for Nursing Home Residents With Advanced Dementia

Better advance care planning (ACP) can help promote goal-directed care in patients with advanced dementia. To test whether an ACP video (vs usual care) has an effect on documented advance directives, level of care preferences, goals-of-care discussions, and burdensome treatments among nursing home residents with advanced dementia. The Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE) trial was a cluster randomized clinical trial conducted between February 2013 and July 2017, at 64 Boston-area nursing homes (32 facilities per arm). A total of 402 residents with advanced dementia and their proxies (intervention arm, n = 212; control arm, n = 190) were assessed quarterly for 12 months. A 12-minute ACP video for proxies with written communication of their preferred level of care (comfort, basic, or intensive) to the primary care team. The primary outcome was the proportion of residents with do-not-hospitalize (DNH) directives by 6 months. Secondary outcomes included preference for comfort care, documented directives to withhold tube-feeding and intravenous hydration, documented goals-of-care discussions, and burdensome treatments (hospital transfers, tube-feeding, or parenteral therapy) per 1000 resident-days. Exploratory analyses examined associations between trial arm and documented advance directives when comfort care was preferred. The mean age of the 402 study residents was 86.7 years [range, 67-102 years]; 350 were white (87.1%) and 323 were female (80.3%), with DNH directives that by 6 months did not differ between arms (63% in both arms; adjusted odds ratio [AOR], 1.08; 95% CI, 0.69-1.69). Preferences for comfort care, directives to withhold intravenous hydration, and burdensome treatments did not differ between arms. Residents in intervention vs control facilities were more likely to have directives for no tube-feeding at 6 months (70.10% vs 61.90%; AOR, 1.79; 95% CI, 1.13-2.82) and all other time periods, and documented goals-of-care discussions at 3 months (16.10% vs 7.90%; AOR, 2.58; 95% CI, 1.20-5.54). When comfort care was preferred, residents in the intervention arm were more likely to have both DNH and no tube-feeding directives (72.20% vs 52.80%; AOR, 2.68; 95% CI, 2.68-5.85). An ACP video did not have an effect on preferences, DNH status, or burdensome treatments among residents with advanced dementia, but did increase directives to withhold tube-feeding. When proxies preferred comfort care, advance directives of residents in the intervention arm were more likely to align with that preference. clinicaltrials.gov Identifier: NCT01774799.

Do-Not-Hospitalize Orders in Nursing Homes: "Call the Family Instead of Calling the Ambulance".

To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place. Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014. Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010. Nursing facility staff members (N = 31). A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes. DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred. In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.

Advance Directives Among Nursing Home Residents with Mild, Moderate and Advanced Dementia (S715)

•An understanding of which demographic factors are most likely to impact completion of advance directives in nursing home residents with dementia.•An understanding of which clinical stages of dementia are most likely to be associated with advance directives among nursing home patients. For nursing home residents with complex care needs, particularly those with dementia, advance directives (ADs) provide essential guidance around medical decision-making. Identifying factors affecting AD completion is crucial to improving patient-centered care and efficiency of care in this population. To describe the prevalence of ADs among nursing home residents with mild, moderate, or advanced stage dementia and resident factors associated with ADs. We constructed a cohort of nursing home residents from five states in the U.S. (Minnesota, Massachusetts, Pennsylvania, Florida, California) in 2007 and 2008. Residents were identified and assessed using the Minimum Data Set 2.0 (MDS) linked to Medicare claims (Parts A and D) and the Medicare denominator file. Eligible residents were aged 65 and older and had a duration of stay ≥90 days and a diagnosis of dementia and a Cognitive Performance Scale (CPS) score ≥ 1. Stage of dementia was classified using the CPS. ADs were defined as the presence of a living will; do-not-resuscitate order (DNR); or do-not-hospitalize (DNH) order, medication restriction, and feeding restriction. Logistic regression was used to identify resident characteristics associated with ADs. The final sample size was 226,926. Overall, forty percent (n=91,547) had no AD. Presence of DNR, DNH, feeding restriction and medication restriction orders increased with dementia severity. In adjusted analysis, older age, female sex, white race, higher education, and being married or widowed were associated with the presence of an AD (all p’s < .001). ADs are more common among nursing home residents with advanced stages of dementia. Presence of ADs is influenced by a number of demographic factors.

Advance Care Planning in Nursing Home Patients With Dementia: A Qualitative Interview Study Among Family and Professional Caregivers

ObjectiveThe aim of this study was to describe the process of advance care planning (ACP) and to explore factors related to the timing and content of ACP in nursing home patients with dementia, as perceived by family, physicians, and nurses. DesignA qualitative descriptive study. MethodsA total of 65 in-depth qualitative interviews were held with families, on-staff elderly care physicians, and nurses of 26 patients with dementia who died in the Dutch End Of Life in Dementia (DEOLD) study. Interviews were coded and analyzed to find themes. ResultsFamily, nurses, and physicians of all patients indicated they had multiple contact moments during nursing home stay in which care goals and treatment decisions were discussed. Nearly all interviewees indicated that physicians took the initiative for these ACP discussions. Care goals discussed and established during nursing home stay and the terminology to describe care goals varied between facilities. Regardless of care goals and other factors, cardiopulmonary resuscitation (CPR) and hospitalization were always discussed in advance with family and commonly resulted in a do-not-resuscitate (DNR) and a do-not-hospitalize (DNH) order. The timing of care planning discussions about other specific treatments or conditions and the content of treatment decisions varied. The factors that emerged from the interviews as related to ACP were general strategies that guided physicians in initiating ACP discussions, patient's condition, wishes expressed by patient or family, family's willingness, family involvement, continuity of communication, consensus with or within family, and general nursing home policy. Two influential underlying strategies guided physicians in initiating ACP discussions: (1) wait for a reason to initiate discussions, such as a change in health condition and (2) take initiative to discuss possible treatments (actively, including describing scenarios). ConclusionsACP is a multifactorial process, which may lean on professional caregivers' guidance. The most acute decisions are covered in advance, but a responsive as well as a proactive style is seen with other treatment decisions. Further research is needed to increase understanding of whether and how the physicians' strategies affect care processes and outcomes.

Do‐Not‐Hospitalize Orders for Individuals with Advanced Dementia: Healthcare Proxies' Perspectives

To determine how well healthcare proxies (HCPs) understand do-not-hospitalize (DNH) orders and why they may or may not initiate them. Semistructured qualitative interviews. Two nursing homes in western Massachusetts. HCPs of nursing home residents with advanced dementia. In-depth interviews were audiotaped and transcribed verbatim. Data were qualitatively analyzed in an iterative process, and emergent concepts were conceptually ordered into explanatory categories. Pertinent demographic and clinical information was collected from the Minimum Data Set (MDS) and patient charts. Sixteen of 31 eligible HCPs were interviewed. Major findings included barriers to and facilitators of initiating DNH orders. Barriers included a perceived lack of physician involvement in decision-making and limited understanding of DNH orders and the resident's prognosis. Facilitators included a HCPs' personal experience in health care, understanding the prognosis of advanced dementia, and a desire to limit resident distress. The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes.

The Cost-Effectiveness of the Decision to Hospitalize Nursing Home Residents With Advanced Dementia

ContextNursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. ObjectivesTo estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. MethodsNH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. ResultsCompared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, −$4958 and INB for hospital transfer for pneumonia, −$6355). ConclusionTreatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.

Hospital Transfers of Nursing Home Residents with Advanced Dementia

To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia. Prospective cohort study. Twenty-two Boston, Massachusetts-area NHs. Three hundred twenty-three NH residents with advanced dementia. Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer. The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer. The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.

Decisions to Forgo Hospitalization in Advanced Dementia: A Nationwide Study

To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia. Cross-sectional study. All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states. NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521). Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas). Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations. Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.

Barriers to the Implementation of Palliative Care in the Nursing Home

Although residents of nursing homes (NH) could greatly benefit from palliative care, most NHs do not have a clear understanding of how to incorporate the philosophy of palliative care into the mainstream of medical care. This lack of process can lead to barriers between members of the interdisciplinary team at the NH. Specifically, barriers can result from poor communication, lack of coordination of care, inadequate pain and symptom control, and differences in the perceived value of research in the NH setting. The National Consensus Project for Quality Palliative Care lists core outcomes for palliative care. 1 Among these core outcomes are high-quality communication, coordination of care, and control of pain and symptoms. Palliative care is care given by an interdisciplinary team that focuses on the prevention and relief of suffering for patients and their families when the patient has a life-limiting condition. 2 The interdisciplinary team usually consists of a physician, nurse, chaplain, and social worker, but can also include volunteers, pharmacists, nursing assistants, nutritionists, and therapists. The NH is an ideal location for the practice of palliative care because an interdisciplinary team already exists and numerous residents at the NH have lifelimiting conditions. MAGNITUDE OF THE PROBLEM Currently, 66% of residents remain in nursing facilities to die rather than being transferred to a hospital for their final days. 3 Now that more people are dying in the NH coupled with the growing percentage of people who spend or will spend time in a NH, it becomes imperative that the principles of palliative medicine be practiced by all health care professionals who work at the NH. When we tried to implement palliative care in a NH, we encountered barriers because of poor communication, lack of coordination of care, inadequate pain and symptom control, and the perceived insignificant value of palliative care research by members of the interdisciplinary team at the NH. The following cases illustrate the magnitude of the problem with implementing effective palliative care in the NH. BARRIERS SURROUNDING COMMUNICATION ● A 90-year-old white female with end-stage Alzheimer’s dementia: The NH medical director discussed goals of care with the patient’s health care surrogate (HCS). The HCS stated that the goals were comfort-only and the medical director explained the do not hospitalize (DNH) order. The HCS wanted DNH for the patient; therefore, the physician wrote this order. The NH director of nursing questioned the DNH order. She thought it meant the patient would receive no treatment. She also did not think the patient had a terminal diagnosis. The physician should have communicated and explained the orders with the nursing staff when the orders were written. The physician also should have written “End-stage Alzheimer’s dementia” along with the DNH order, which would have communicated to the staff the natural progression of Alzheimer’s dementia. The barriers in this case stem from a lack of communication about the natural progression of Alzheimer’s dementia and the meaning of DNH.

Advance Care Planning by or on Behalf of Peritoneal Dialysis Patients in Long-Term Care

Advance care planning (ACP) is recommended for dialysis patients, especially those living in long-term-care facilities. Factors influencing ACP and the effect of plans on outcome are incompletely studied. We performed a retrospective chart review and follow-up of all peritoneal dialysis patients admitted to an academic nursing home between 1986 and 2000 and abstracted demographics, comorbidities, functional status as activities of daily living (ADL) score, documentation of ACP, and actual interventions. Of 109 patients, 108 had ACP; of these, patients participated in 71%. Plans to do not attempt resuscitation (DNAR) were associated with the presence of coronary disease (odds ratio, 4.24; confidence interval [CI], 1.49 to 12.02), lower ADL score (odds ratio, 1.22; CI, 1.08 to 1.38), and older age (odds ratio, 1.04; CI, 1.0007 to 1.09). Plans to do not hospitalize (DNH) were associated with ADL score only (odds ratio, 1.26; CI, 1.07 to 1.48). Patients with DNAR plans had poorer 3-, 6-, and 12-month survival (P < 0.02), but not after adjustment for age of 75 years or older, poor functional status, coronary disease, and decubiti. Plan compliance was limited. DNH plans were not associated with the likelihood of hospitalization (5 of 14 versus 42 of 93 patients) or length of stay (11.0 +/- 16.4 versus 8.0 +/- 15.1 days). Compliance with DNAR plans was determined for 81 of 108 patients. No patient with a DNAR plan had resuscitation attempted. Only 7 of 46 patients with plans to undergo resuscitation had it attempted. For these chronically ill patients, age and functional status strongly influence DNAR and DNH plans. ACP was not decisive in determining events during acute illness.

Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit

To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. Retrospective cohort study. Nursing homes in the United States. Medicare admissions to SNFs in 2001 (n=1,962,742). Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.