Predictors of Advance Directive Changes in Ontario Nursing Home Residents: A Case-Control Study

Area of Science:

• Gerontology
• Health Services Research
• Palliative Care

Background:

• Goals of Care (GOC) discussions guide advance directive (AD) decisions, including do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders.
• The optimal timing and triggers for initiating GOC discussions in nursing home (NH) residents remain unclear.
• This study examines emergency department (ED) utilization and clinical factors influencing subsequent AD changes.

Purpose of the Study:

• To investigate factors associated with changes in advance directives (AD) among nursing home (NH) residents.
• To identify predictors of AD modification, focusing on recent emergency department (ED) use and clinical status.
• To inform the timing and approach for goals of care (GOC) discussions.

Main Methods:

• A nested case-control study utilized linked administrative health data from Ontario, Canada (2013-2019).
• Residents with and without AD changes were matched 1:1 based on demographics and admission details.
• Conditional logistic regression analyzed associations between exposures (e.g., recent ED use, clinical status) and incident AD change.

Main Results:

• The study included 27,942 NH residents (mean age 84 years, 67.1% female).
• Recent hospitalization (OR 2.01), end-stage disease (OR 1.89), and being bedfast (OR 1.82) significantly predicted AD changes.
• Baseline ADs included "DNR Only," "Full Code," and "DNR+DNH."

Conclusions:

• Recent hospitalization, end-stage disease, and immobility are key predictors for advance directive changes in NH residents.
• These predictors offer critical opportunities to re-evaluate and re-initiate goals of care discussions.
• Proactive GOC discussions are essential for aligning care with resident preferences.