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Impaired nursing home residents may not get the end-of-life care they want, even if they have an advance directive

Nursing home residents with cognitive and/or functional impairments may not have their care preferences honored, even when they have completed a durable power of attorney and advance directives, according to a recent study. Nursing staff need to work closely with impaired residents' surrogates when residents are admitted to nursing homes to identify their advance directive preferences and ensure that their autonomy and dignity are respected, notes Linda E. Moody, Ph.D., of the University of South Florida. At the time of the study, Dr. Moody was Senior Nurse Scholar-in-Residence at the Agency for Healthcare Research and Quality.

Dr. Moody and her colleagues analyzed data from the 1996 Medical Expenditure Panel Survey-Nursing Home Component (MEPS-NHC) to examine advance directive preferences by level and type of resident impairment. Residents who were more cognitively impaired (score of 3-4 on a cognitive scale) were significantly more likely than less cognitively impaired residents (score of 1) to have advance directive preferences that were not completed for living wills (18.2 vs. 17.7 percent), do-not-resuscitate (DNR) orders (54.2 vs. 43.1 percent), and no hospitalization (5.0 vs. 3.4 percent) directives. For functionally impaired residents, there were significant differences only for DNR orders, with 53 percent of those with impairment in six activities of daily living not having preferred DNR orders versus 29 percent of those with no functional impairments.

Results also confirmed that nursing home residents with cognitive and/or functional impairment were more likely to suffer from adverse medical events, specifically infections. Three infectious-related conditions (urinary tract infections, pneumonia, and tuberculosis) were found more often among impaired nursing home residents, suggesting that impaired residents are more likely than nonimpaired residents to be undernourished and immunosuppressed. Because these infections are thought to be preventable, residents who are admitted with cognitive and/or functional impairment should be assessed for nutritional risk or for immunocompetence so that appropriate interventions can be applied early.

See "Advance directives preferences of functionally and cognitively impaired nursing home residents in the United States" by Dr. Moody, Brent J. Small, Ph.D., and Cheryl B. Jones, Ph.D., in the March 2002 Journal of Applied Gerontology 21(1), pp. 103-118.

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