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Advance Directives Change Frequently in Nursing Home Residents
Hannah J Wong1, Hsien Seow2, Anastasia Gayowsky3
1School of Health Policy & Management, York University, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
Journal of the American Medical Directors Association
|June 17, 2024
Summary
Advance directive (AD) changes are dynamic in nursing homes. Frequent AD reviews, especially after health changes, are crucial for accurate care planning and adherence.
Area of Science:
- Gerontology and Geriatric Care
- Health Services Research
- Palliative Care
Background:
- Advance directives (ADs), including do not resuscitate (DNR) and do not hospitalize (DNH) orders, guide end-of-life care in nursing homes.
- Understanding the patterns and frequency of AD changes is essential for ensuring resident wishes are honored.
Purpose of the Study:
- To describe the rate, timing, and pattern of changes in advance directives (ADs) for do not resuscitate (DNR) and do not hospitalize (DNH) orders among new nursing home admissions.
- To identify factors associated with AD changes in this population.
Main Methods:
- Retrospective cohort study of 102,541 nursing home admissions in Ontario, Canada (2013-2017).
- Residents categorized into Full Code, DNR Only, or DNR+DNH groups.
- Poisson regression used to analyze AD changes, controlling for clinical and sociodemographic variables.
Main Results:
- 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH residents experienced at least one AD change.
- Median time to first AD change ranged from 26 to 55 weeks.
- Residents with DNR orders or surrogate decision-makers at admission had lower AD change rates.
Conclusions:
- ADs are dynamic, and static measurements underestimate change, potentially misrepresenting care effectiveness.
- More frequent AD reviews are recommended, particularly after acute health changes, to ensure currency.
- Dynamic AD assessment is vital for accurate resident care planning and adherence to preferences.
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