Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

BMC Geriatrics

Rhéda Adekpedjou¹  Paul C. Hébert¹  Andrew P. Costa²  John Hirdes³  George A. Heckman⁴ 

[1] Carrefour de l’innovation et de l’évaluation en santé, Centre Hospitalier de l’Université de Montréal, Montréal, Canada;McMaster University, Hamilton, Canada;School of Public Health Sciences, University of Waterloo, 200 University Avenue West, N2L 3G1, Waterloo, Ontario, Canada;School of Public Health Sciences, University of Waterloo, 200 University Avenue West, N2L 3G1, Waterloo, Ontario, Canada;Schlegel Research Institute for Aging, Waterloo, Canada;

关键词: Advance care planning;    Long-term care homes;    Nursing homes;    interRAI;   

DOI  :  10.1186/s12877-021-02699-5

来源: Springer

【 摘 要 】

BackgroundResidents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes.MethodsIn this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015.ResultsWe report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively.ConclusionEven though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

【 授权许可】

CC BY