The Journal of Post-Acute and Long-Term Care Medicine

Taeko Nakashima, Yuchi Young*, and Wan-Hsiang Hsu



Objectives: This study aims to examine whether an advance directive “Do Not Hospitalize” (DNH) would be effective in reducing hospital/emergency department (ED) transfers. Similar effects in residents with dementia were also examined.

Design: Cross-sectional study.

Setting/subjects: New York State (NYS) nursing home residents (n = 43,024).

Measurements and analysis: The Minimum Data Set 2.0 was used to address the study aims. Advance directives with an indication of DNH and Alzheimer disease/dementia other than Alzheimer disease were coded (yes vs no). Logistic regression analyses were performed to quantify the relationship between DNH orders and hospital/ED transfers while adjusting for confounders.

Results: Our results show that 61% of nursing home residents had do-not-resuscitate orders, 12% had feeding restrictions, and only 6% had DNH orders. Residents with DNH orders had significantly fewer hospital stays (3.0% vs 6.8%, P <.0001) and ED visits (2.8% vs 3.6%, P = .03) in the last 90 days than those without DNH orders. Dementia residents with DNH orders had significantly fewer hospital stays (2.7% vs 6.3%, P < .0001) but not ED visits (2.8% vs 3.5%, P = .11) than those without DNH orders. After adjusting for covariates in the model, the results show that for residents without DNH orders, the odds of being transferred to a hospital was significantly higher (odds ratio = 2.23, 95% confidence interval = 1.77–2.81) than those with DNH orders.

Conclusion: Residents with DNH orders had significantly fewer transfers. This suggests that residents’ end-of-life care decisions were respected and honored. Efforts should be made to encourage nursing home residents to complete DNH orders to promote integration of the resident’s values and goals in guiding care provision toward the end of life.

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* Denotes CSDA Associates, Affiliates, and Staff