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We examined the charts of 911 nursing home patients in Hennepin County, Minnesota, to determine the prevalence of written do-not-resuscitate (DNR) orders. Information regarding demographic characteristics, and whether a surrogate decisionmaker was available and participated in the decision, was also collected. Twenty-seven percent of patients had DNR orders. Ninety percent of all patients had potentially available surrogate decisionmakers. However, for 31% of patients with DNR orders, there was no documentation of patient or surrogate participation in the DNR decision. Univariate analysis identified female sex; increased age, level of care (skilled versus intermediate), presence of a potential surrogate decisionmaker, and increasing length of time since nursing home admission as factors associated with presence of DNR orders. When a logistic regression model was used, increased age, increased length of time since nursing home admission, skilled versus intermediate level of care, and presence of a surrogate decisionmaker were independently associated with presence of DNR status. Several variables are independently associated with written DNR orders; their relationship to the factors physicians use in decision making requires further study.

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.