Factors associated with treatment restriction orders and hospice in older nursing home residents

The purpose of the study is to examine factors associated with do-not-resuscitate orders, do-not-hospitalise orders and hospice care in older nursing home residents at admission.

Although hospice care is viewed as the 'gold standard,' geographic availability and financial reimbursement limits its use. Treatment restriction orders may represent alternative approaches to defining wishes for end-of-life care.

A descriptive correlational study design was employed to examine the use of four care directives and hospice in newly admitted older people NH residents using Maryland Minimum Data Set 2.0 and the On-Line Survey Certification and Reporting in 2000. Analyses reflected 10,023 unduplicated admission records from 77 NHs.

The prevalence of do-not-resuscitate and do-not-hospitalise orders at admission was 28 and 3.4%, respectively. A very small percentage of residents received hospice care on admission (1.7%). Appropriately, health-related characteristics had a strong influence on use of do-not-resuscitate orders, do-not-hospitalise orders and hospice care. However, identified predictors were varied among do-not-resuscitate orders, do-not-hospitalise orders and hospice care. Moreover, multivariate logistical modelling found that non-Medicare insurance significantly influenced the likelihood of do-not-resuscitate orders, do-not-hospitalise orders and hospice uses; White race increased the likelihood of having a do-not-resuscitate and do-not-hospitalise order. Treatment restriction orders were associated with an increased of likelihood of hospice use.

As policy and reimbursement barriers to hospice use are likely to persist, treatment restriction orders should be used to focus communication with residents, families and providers, with the ultimate goal of more widespread implementation of hospice care principles.

White race was consistently associated with increasing the likelihood of having do-not-resuscitate and do-not-hospitalise orders, supporting the importance of cultural sensitivity in advanced care planning. With the association between do-not-hospitalise orders and hospice use, treatment restriction orders should be used as potential triggers to prompting end-of-life care.