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Long-term Care

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Nursing homes generally respect residents' do-not-hospitalize orders, but not always

A do-not-hospitalize (DNH) order is a type of advance directive which indicates that the resident or responsible party (e.g., relative or legal guardian) does not wish the resident to be hospitalized. Nursing homes generally respect do-not hospitalize (DNH) orders of residents, but this is not always the case.

A study involving a national sample of nursing home residents found that residents with DNH orders were half as likely to be hospitalized as residents without such orders. This finding suggests that nursing home compliance with residents' preferences for care is superior to that found in hospital inpatient settings, yet 13 percent of residents in this study who had DNH orders were hospitalized directly from their sampled nursing home.

Nursing homes should implement more consistent and rigorous policies to ensure that patient preferences for medical care are honored, suggests Aram Dobalian, Ph.D., J.D., of the University of Florida. Dr. Dobalian analyzed data from the nationally representative 1996 Nursing Home Component of the Medical Expenditure Panel Survey to determine whether nursing homes comply with residents' DNH orders prohibiting inpatient hospitalization. The study was supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00046).

The analysis showed that only 3 percent of nursing home residents had DNH orders. These residents were half as likely to be hospitalized. Residents in not-for-profit or public facilities were less likely to be hospitalized than those in for-profit homes.

Hospitalization was more likely among men, racial or ethnic minorities, those with more diagnosed health conditions, and those in facilities in the South compared with those in the Midwest. Hospitalized residents with DNH orders had no limitations in daily living activities, were not located in hospital-based nursing homes, were less likely to be in a for-profit facility, and were sicker than nonhospitalized residents with DNH orders.

The study findings were limited by the mere 3 percent of residents with DNH orders. The low prevalence of DNH orders suggests the possibility that these orders are being underused. It's also possible that some residents with DNH orders chose to permit hospitalization despite their previous preference to forego it, notes Dr. Dobalian.

See "Nursing facility compliance with do-not-hospitalize orders," by Dr. Dobalian, in the April 2004 Gerontologist 44(2), pp. 159-165.

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