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Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections


  • Supported by Grant HS08551 from the Agency for Healthcare Research and Quality and Dr. Mehr's Robert Wood Johnson Foundation Generalist Physician Faculty Scholars award. Dr. Kruse was supported by Institutional National Research Service Award Number PE10038 from the Health Resources and Services Administration.

Address correspondence to Steven C. Zweig, MD, MSPH Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, Columbia, MO 65212. E-mail:


(See editorial comments by Dr. Joan Teno on pp 159–160)

Objectives: To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).

Design: Prospective cohort.

Setting: Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.

Participants: NH residents with a LRI (n=1031).

Measurements: Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.

Results: Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49–0.97).

Conclusion: DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.