Treatment decisions in a skilled-nursing facility: discordance with nurses' preferences

Hospitalization transfers from a skilled-nursing facility were studied. A hierarchically arranged questionnaire on acute medical deterioration and treatment aggressiveness was used to study the degree of discordance between the transfers actually made and the preferences of nursing home head nurses. According to the nurses, 37 per cent of the patients involved should not have been hospitalized even under the most compelling circumstances; however, 76 per cent of this subgroup had in fact been hospitalized under physician's orders. The nurses would have refrained from instituting any new treatment in 14 per cent of the cases, all of which involved chronic neurological impairments; 36 per cent of this subgroup had nevertheless been hospitalized in the 12 months prior to the study.