Decisions to Forgo Hospitalization in Advanced Dementia: A Nationwide Study

Authors

  • Susan L. Mitchell MD, MPH,

    1. From the *Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MassachusettsCenter for Gerontology and Health Care Research, Department of Community Health, Brown Medical School, Providence, Rhode Island.
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  • Joan M. Teno MD, MS,

    1. From the *Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MassachusettsCenter for Gerontology and Health Care Research, Department of Community Health, Brown Medical School, Providence, Rhode Island.
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  • Orna Intrator PhD,

    1. From the *Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MassachusettsCenter for Gerontology and Health Care Research, Department of Community Health, Brown Medical School, Providence, Rhode Island.
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  • Zhanlian Feng PhD,

    1. From the *Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MassachusettsCenter for Gerontology and Health Care Research, Department of Community Health, Brown Medical School, Providence, Rhode Island.
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  • Vincent Mor PhD

    1. From the *Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, MassachusettsCenter for Gerontology and Health Care Research, Department of Community Health, Brown Medical School, Providence, Rhode Island.
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  • This paper was presented, in part, as an oral abstract presentation at the American Geriatric Society's Annual Scientific Meeting in Chicago, Illinois, May 5, 2006.

Address correspondence to Susan L. Mitchell, MD, MPH, Hebrew Senior Life, 1200 Center Street, Boston, MA 02131. E-mail: smitchell@hrca.harvard.edu

Abstract

OBJECTIVES: To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia.

DESIGN: Cross-sectional study.

SETTING: All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states.

PARTICIPANTS: NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521).

MEASUREMENTS: Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas).

RESULTS: Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations.

CONCLUSION: Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.

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