Code status decision-making in a nursing home population: processes and outcomes

Psychological Attachment Orientations of Surrogate Decision-Makers and Goals-of-Care Decisions for Brain Injury Patients in ICUs

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To determine whether ICU surrogates with “insecure” psychologic attachment orientations are more prone to requesting tracheostomy and gastrostomy (i.e., life-sustaining therapy) for severe acute brain injury patients with poor prognosis compared to surrogates with “secure” orientations.

Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective, longitudinal study

BACKGROUND

No data-based evidence is available regarding the best time for nursing home nurses to obtain residents' signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries.

OBJECTIVES

The purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not-resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents' mortality in Taiwan.

DESIGN

Retrospective, longitudinal design.

SETTING

Six nursing homes in Taiwan.

PARTICIPANTS

Nursing home residents (N=563).

METHODS

Data were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models.

RESULTS

The mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds=2.57) and the number of transfers to hospital (odds=1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10-3.98; p=0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99-3.59; p=0.05).

CONCLUSION

Early research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives.

Advance care plans for CPR or mechanical ventilation in patients with dementia

Early development of advance care plans is an ethical and supportive intervention providers can offer patients and families facing a dementia diagnosis.

Prevalence and related factors of do-not-resuscitate directives among nursing home residents in Taiwan

OBJECTIVES

To report the prevalence of Do-Not-Resuscitate (DNR) directives and to explore the factors associated with the presence of DNR directives among nursing home residents in Taiwan.

DESIGN

A cross-sectional, correlation study.

SETTING

Seven nursing homes in southern Taiwan.

PARTICIPANTS

Nursing home residents and their family surrogates.

MEASUREMENTS

Data were collected using chart abstraction and a questionnaire survey. We used multivariate logistic regression to analyze the associations between resident, family surrogate, and facility characteristics and the presence of DNR directives.

RESULTS

Among the 201 nursing home residents, 33 (16.4%) had DNR directives and 91% of the directives had been put in place by family surrogates. Our data revealed that resident's age (OR = 1.06, 95% CI = 1.01-1.12), cognitive function score (OR = 0.91, 95% CI = 0.85-0.97), prior DNR discussion between physician and family surrogate (OR = 4.09, 95% CI = 1.53-10.96), and nursing home with DNR policy (OR = 17.71, 95% CI = 5.87-53.46) were independently and associated with the presence of a DNR directive.

CONCLUSIONS

The prevalence of DNR directives among Taiwanese nursing home residents was lower than that in other countries. Our results point out the lack of DNR policy in most Taiwanese nursing homes and highlight the need for policy makers to implement further regulations. Meanwhile, education about advance directives is warranted to increase public and professional awareness and to facilitate empowerment of the increasing number of frail elderly nursing home residents in Taiwan.

Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians

The do-not-resuscitate order, introduced nearly a half century ago, continues to raise questions and controversy among health care providers and patients. In today's society, the expectation and availability of medical interventions, including at the end of life, have rendered the do-not-resuscitate order particularly relevant. The do-not-resuscitate order is the only order that requires patient consent to prevent a medical procedure from being performed; therefore, informed code status discussions between physicians and patients are especially important. Epidemiologic studies have informed our understanding of resuscitation outcomes; however, patient, provider, and institutional characteristics account for great variability in the prevalence of do-not-resuscitate orders. Specific strategies can improve the quality of code status conversations and enhance end-of-life care planning. In this article, we review the history, epidemiology, and determinants of do-not-resuscitate orders, as well as frequently encountered questions and recommended strategies for discussing this important topic with patients.

Planning for End-of-Life Care

The authors examined Black-White differences in the likelihood of completing written advance directives for end-of-life health care and engaging in informal verbal communication about advanced wishes. Data from the 1998 Health and Retirement Study (HRS) were combined with data from the 2000 HRS exit interview to analyze Black and White participants' completion rates. Whites were more likely than Blacks to grant durable power of attorney for health care, to complete a written will, and to informally communicate their wishes; group differences remained after controlling for personal characteristics. Also, Blacks were less likely than Whites to engage in more than one form of end-of-life planning. The authors speculate that sociocultural differences in trust in the medical system and knowledge about advance directives may partially account for these findings. The findings may aid policy makers and practitioners in increasing the level of participation in advance directives.

Which Advance Directive Matters? An Analysis of End-of-Life Decisions Made in Nursing Homes

This study clarifies the role of advance directives in the process of decision making in nursing homes. Physicians reported on the actual use of advance directives in a medical decision-making process related to status changes in 70 nursing home residents (mean age = 89 years). Charts were also reviewed to assess the specifics of the advance directives. Despite a high prevalence of advance directives, the directives themselves had a very limited role in affecting treatments. The physicians surveyed viewed directives related to hospitalization as the most useful, though these were not the most available directives. The attention and format given to advance directives in the nursing home may need to be reevaluated.

Environmental contexts of ultimate decisions: why White nursing home residents are twice as likely as African American residents to have an advance directive

OBJECTIVES

The purpose of this study was to determine the extent to which observed differences between White and African American nursing home residents in having an advance directive are attributable to differences between the groups in personal characteristics, the organizational environment of the nursing home, and the geographical environment of the counties in which the nursing homes are located.

METHODS

By using the Medical Expenditure Panel Survey Nursing Home Component matched with county-level measures from the Area Resource File, we modeled the probability of having an advance directive as a function of nursing home resident, facility, and county characteristics for African American and White residents.

RESULTS

The probability of having an advance directive was 27.0% for African American residents and 63.6% for White residents. Nearly half of this 36.6 percentage point gap could be explained by group differences in personal, facility, and county characteristics.

DISCUSSION

County characteristics play a more prominent role than do personal or facility measures in explaining the observed ethnic gap in the prevalence of advance directives. Additional studies should focus further on geographic, health status, and attitudinal variations among nursing home residents that may account for the remaining ethnic difference in the prevalence of advance directives among nursing home residents.

Recent trends in advance directives at nursing home admission and one year after admission

PURPOSE

Advance directives are important planning and decision-making tools for individuals in nursing homes.

DESIGN AND METHODS

By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission.

RESULTS

The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type.

IMPLICATIONS

The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time.

Current Research Findings on End-of-Life Decision Making Among Racially or Ethnically Diverse Groups

PURPOSE

We reviewed the research literature on racial or ethnic diversity and end-of-life decision making in order to identify key findings and provide recommendations for future research.

DESIGN AND METHODS

We identified 33 empirical studies in which race or ethnicity was investigated as either a variable predicting treatment preferences or choices, where racial or ethnic groups were compared in their end-of-life decisions, or where the end-of-life decision making of a single minority group was studied in depth. We conducted a narrative review and identified four topical domains of study: advance directives; life support; disclosure and communication of diagnosis, prognosis, and preferences; and designation of primary decision makers.

RESULTS

Non-White racial or ethnic groups generally lacked knowledge of advance directives and were less likely than Whites to support advance directives. African Americans were consistently found to prefer the use of life support; Asians and Hispanics were more likely to prefer family-centered decision making than other racial or ethnic groups. Variations within groups existed and were related to cultural values, demographic characteristics, level of acculturation, and knowledge of end-of-life treatment options. Common methodological limitations of these studies were lack of theoretical framework, use of cross-sectional designs, convenience samples, and self-developed measurement scales.

IMPLICATIONS

Although the studies are limited by methodological concerns, identified differences in end-of-life decision-making preference and practice suggest that clinical care and policy should recognize the variety of values and preferences found among diverse racial or ethnic groups. Future research priorities are described to better inform clinicians and policy makers about ways to allow for more culturally sensitive approaches to end-of-life care.

Which signs and symptoms warrant involvement of medical staff? The definition and identification of status-change events in the nursing home

In this article, the authors clarify the concept of status-change events (a significant clinical change that calls for medical follow-up by a physician) by providing preliminary descriptions of these events, and attempting to differentiate them from incidents that did not qualify as status-change events. Participants were residents from a large, nonprofit nursing home. Data were collected about the source of information, the nature of the incident, whether it qualified as a status-change event, and the reason (if any) for disqualification. The most common incidents involved in status-change events were troubled breathing, aspiration, fracture, and hypotension. The most common incidents that did not qualify as status-change events were continuing pneumonia, bruises, lacerations, disorientation, and blood pressure abnormalities. A wide range of physical ailments characterized both status-change events and incidents that did not qualify as status-change events. The main reason an incident did not qualify was because it did not warrant contacting the physician. The nature of the incident is insufficient in itself to determine whether the incident qualifies as a status-change event. The process for identifying and analyzing status-change events in the nursing home requires several steps and much persistence.

Advance care planning among residents in long-term care

This study was conducted to determine whether two types of advance directives exist for individuals residing in long-term care facilities. Findings were based on data from the Medical Expenditure Panel Study-Nursing Home Component (MEPS-NHC), a survey using a two-stage stratified probability sample of nursing homes and residents to produce valid national estimates of the nursing home population in the United States. The two types of advance directives included basic, i.e., living will or do-not-resuscitate (DNR) order, and progressive (do-not-hospitalize order or orders restricting feeding, medication, or other treatment). Approximately 59 percent of long-term care residents had a basic advance directive, 9 percent have a progressive directive, and 60 percent have some type of directive. Logistic regression results indicate that the factors associated with the likelihood of each type of directive differ considerably, and only two variables (African American ethnicity and less time in the facility) were associated with a reduced likelihood of having either type of directive. Our results indicate that the two proposed types of advance directives are distinct with regard to the variables predicting each.

Factors associated with the time nurses spend at the bedsides of seriously ill patients with poor prognoses

BACKGROUND

Little is known about the time health professionals spend with inpatients that are close to the end of life.

SUBJECTS AND METHODS

We asked day-shift nurses to use a standardized log sheet to record how much time they spent in various categories of activity for 146 seriously ill medical inpatients with poor prognoses at 2 teaching hospitals.

RESULTS

The mean patient age was 68, and the mean APACHE-III physiology score 28; 59% were white, 56% were women, 41% had cancer or HIV, and 81% had do not resuscitate (DNR) orders. The mean amount of time nurses spent with patients per 12-hour day shift was 53 min. In bivariate analyses, sex, religion, diagnosis and insurance status were not associated with nursing bedside time. In an ANOVA model, patients with DNR orders received more time than those without DNR orders (56 vs. 39 min, P = 0.04), and white patients received more bedside time than nonwhites (57 vs. 46 min, P = 0.01), even after controlling for severity of illness and DNR status. Among the 47 mentally alert patients who could be interviewed, symptom severity, quality of care, and satisfaction ratings were not associated with nursing bedside time.

CONCLUSIONS

In this population, nurses spent less time with nonwhite patients and more time with patients with DNR orders. That patients with DNR orders received more time may be reassuring. However, further investigation will be required to confirm these results, to understand why nonwhite patients appear to have received less bedside nursing time, and to investigate further the relationship between time, satisfaction, and quality of care.

Medical staff's decision-making process in the nursing home

BACKGROUND

This paper describes the medical decision-making process at the time of status change events in the nursing home.

METHODS

Six male physicians and 3 female nurse practitioners completed questionnaires that described the medical decision-making process for 70 residents of a large nonprofit nursing home.

RESULTS

Hospitalization was the most frequently cited treatment considered and chosen; family members were involved in 39% of decisions, and nurses were involved in 34%. The most important considerations in making a decision were reported to be the resident's quality of life, the relative effectiveness of the treatment options, and the family's wishes. The levels of importance ascribed to the considerations were related to the physician's identity, specific resident characteristics (such as estimated life expectancy), and communication between the physician and resident (such as sharing knowledge of family wishes).

CONCLUSIONS

The decision at the time of a status change event involves multiple conditions, multiple considerations, and multiple treatment options, and tends to result in either an active route, such as hospitalization, or a passive one, such as comfort care. The impact of the individual physician and the physician-resident relationship on this process deserves further investigation.

Persistence of racial disparities in advance care plan documents among nursing home residents

This paper analyzes the association between race and the presence of advance care plan documents (living wills, do not resuscitate (DNR) orders, and do not hospitalize (DNH) orders) in nursing home residents. We conducted secondary analysis of publicly available survey data from the 1996 Medical Expenditure Panel Survey-Nursing Home Component, a nationally representative survey of nursing home residents in the United States. There were 3,747 participants in the survey, weighted to represent 1.56 million nursing home residents in the United States. We found that 20% of U.S. nursing home residents in 1996 had documentation of living wills, 48% had DNR orders, and 4% had DNH orders. African Americans are about one-third as likely as Caucasians to have living wills and one-fifth as likely as Caucasians to have DNR orders; Hispanics are about one-third as likely as Caucasians to have DNR orders and just as likely as Caucasians to have living wills. In conclusion, we found that the presence of advance care plans is related to race, even after controlling for health and other demographic factors. These findings call attention to an area where further research is needed to determine whether residents' (and their families') preferences are being elicited and documented.

I was sick and you came to visit me: time spent at the bedsides of seriously ill patients with poor prognoses

PURPOSE

To learn how much time hospital staff and families spend at the bedsides of seriously ill patients with poor prognoses.

SUBJECTS AND METHODS

An observational study was made of 58 inpatients with cancer, acquired immunodeficiency syndrome, heart failure, obstructive lung disease, or advanced dementia, along with their families and the physicians and nurses working on the medical floors of a university hospital, using direct videotape surveillance of patients' doorways.

RESULTS

The mean (+/-SD) total visitor-minutes spent in the rooms of these patients was 321 +/- 297 minutes per day. On average, patients spent 18 hours 39 minutes per day alone. Mean visit durations were 3 +/- 3 minutes for attending physicians (including consultants), 3 +/- 2 minutes for house officers, 2 +/- 1 minutes for nurses, and 24 +/- 51 minutes for family. The total person-visits per patient per day were 3 +/- 3 for attending physicians, 9 +/- 8 for house officers, 45 +/- 23 for nurses, and 13 +/- 21 for family. Patient sex and age were not significantly associated with total visitor-minutes. In a repeated-measures analysis of variance model, nonwhite patients received fewer total visitor-minutes than did white patients, and patients with dementia received fewer total visitor-minutes than did patients with other diagnoses, especially those with malignancy. Do-not-resuscitate orders were associated with slightly more total visitor-minutes.

CONCLUSIONS

These seriously ill patients with poor prognoses spent most of their time in the hospital alone. Staff visits were frequent but brief. These data do not confirm anecdotal reports that staff members spend less time at the bedsides of patients with do-not-resuscitate orders. Patients with advanced dementia and minority patients appear to have less bedside contact. Further study is required to confirm these findings and to understand optimal visit time for medical inpatients with poor prognoses.

Advance care planning in residential care

BACKGROUND

To provide optimal care for our ageing population, some form of advance care planning (ACP) is essential. Overseas data suggest that the process of ACP and the use of advance care directives (ACD) is suboptimal in residential care institutions. By comparison there are few Australian data.

AIM

To study the process of ACP and the prevalence of ACD in residential care.

METHODS

Cross-sectional study using a questionnaire in the Hunter area, NSW, Australia.

RESULTS

Very low levels of formal advance directives were found (available for only 0.2%). Only 1.1% of residents had 'no-CPR' orders documented in the medical record, while 5.6% had a formal guardian and 2.8% had an enduring guardian. Informal processes of advance planning were much more prevalent. Sixty-five per cent had a 'person responsible' recorded to make decisions for them while in 13% of cases, there was 'staff consensus' as to the optimal care for the patient. However, in 10.6% there was no clear process for medical decision making identified.

CONCLUSIONS

Advanced directives are infrequently used in residential care. Further qualitative and quantitative studies are warranted to explore current processes of decision making.

Sociodemographic factors and the assignment of do-not-resuscitate orders in patients with acute myocardial infarctions

OBJECTIVES

This study examined the impact of sociodemographic and clinical factors, measured at the individual or ecological (zip code) level, on the assignment of do-not-resuscitate (DNR) orders.

DESIGN

This was a retrospective study (analysis of secondary data).

SUBJECTS

We used a probability sample of 974 patients admitted to 30 medium to large California hospitals with acute myocardial infarctions in 1990 to 1991; the sample was originally designed to validate risk adjustment with administrative data.

METHODS

Multivariate logistic regression was used to adjust DNR assignment for age, gender, race, probability of death, functional impairments, payment source, hospital teaching status, and ecological measures of educational attainment, home ownership, and income.

RESULTS

DNR assignment was inversely associated with black race and positively associated with age, probability of death, cognitive impairment, and poor nutritional status. When the probability of death was very low, DNR orders were assigned less frequently to men than to women (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2 to 0.7 at probability of death = 0.10). However, men were significantly more likely to receive a DNR order than women when the probability of death was very high (OR, 4.4; 95% CI, 1.2 to 16.3 at probability of death = 0.90).

CONCLUSIONS

Older, white, sicker, or functionally impaired patients receive DNR orders more often than younger, black, healthier, or functionally intact patients do. Adjusting for these factors, DNR assignment is associated with gender through an interaction involving the probability of death. Future studies should reexamine the impact of these factors on DNR assignment and explore the role of patient values and patient-physician communication barriers.

State variation in nursing home mortality outcomes according to do-not-resuscitate status

BACKGROUND

This study compares mortality outcomes of Medicaid-reimbursed nursing home residents with and without do-not-resuscitate (DNR) orders in two diverse states.

METHODS

We used 1994 Minimum Data Set Plus (MDS+) information on 3215 nursing home residents from two states. We used Kaplan-Meier analyses to examine unadjusted mortality among those with and without DNR orders across states. We used a proportional hazard regression with main and interaction variables to model the likelihood of survival in the nursing home.

RESULTS

Approximately 27% of nursing home residents with DNR orders in State A die within the year, and approximately 40% of nursing home residents with DNR orders in State B die within the year. Regression results indicate that neither having a DNR order nor state of residence were independently associated with mortality. However, residing in State B and having a DNR order was associated with an increased risk of mortality compared with all others in the sample (risk ratio = 1.73; 95% confidence interval = 1.09, 2.75).

CONCLUSION

This study demonstrates that DNR orders are associated with varying mortality across states. Future research is needed to identify the reasons why state level differences exist.

Racial variation in the use of do-not-resuscitate orders

OBJECTIVE

To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample.

MEASUREMENTS

Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates.

MAIN RESULTS

In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p <.001). Rates of orders were also lower ( p <. 001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days.

CONCLUSIONS

The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

A prospective study of the efficacy of the physician order form for life-sustaining treatment

OBJECTIVES

The Physician Orders for Life-Sustaining Treatment (POLST), a comprehensive, one-page order form, was developed to convey preferences for life-sustaining treatments during transfer from one care site to another. This study examined the extent to which the POLST form ensured that nursing home residents' wishes were honored for Do Not Resuscitate (DNR) and requests for transfer only if comfort measures fail.

DESIGN

The study used chart record data to follow prospectively a sample of nursing home residents with the POLST.

SETTING

Eight geographically diverse, long-term, adult-care facilities in Oregon in which the POLST was in use.

PARTICIPANTS

Nursing home residents (n = 180), who had a POLST recording DNR designation and who indicated a desire for transfer only if comfort measures failed, were followed for 1 year.

MEASUREMENTS

For all subjects: treatment and disposition after significant health status changes; orders for narcotics and for provision or limitation of aggressive interventions. For hospitalized subjects: diagnosis, medical interventions, and DNR orders. For those who died: cause and location of death, life-sustaining treatments attempted, and comfort measures provided.

RESULTS

No study subject received CPR, ICU care, or ventilator support, and only 2% were hospitalized to extend life. Of the 38 subjects who died during the study year, 63% had an order for narcotics, and only two (5%) died in an acute care hospital. A total of 24 subjects (13%) were hospitalized during the year. Hospitalized subjects' mean length of stay was 4.9 days, and the mean rate of hospitalizations for all subjects was 174 per 1000 resident years. In 85% of all hospitalizations, patients were transferred because the nursing home could not control suffering. In 15% of hospitalizations (n = 4), the transfer was to extend life, overriding POLST orders.

CONCLUSIONS

POLST orders regarding CPR in nursing home residents in this study were universally respected. Study subjects received remarkably high levels of comfort care and low rates of transfer for aggressive life-extending treatments.