Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit

Levy, Cari; Fish, Ronald H.; Kramer, Andrew M.

doi:10.1111/j.1532-5415.2005.00523.x

Cited by 57 publications

(54 citation statements)

References 32 publications

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“…Caucasian patients, whose emphasis is on autonomy, are more likely to know about and have completed advance directives and DNR orders than African American, Hispanic, and Asian patients. [210][211][212] Factors predicting acceptance of advance directives include education level, prior experience with ventilators, availability of family, severity of illness, and age. 213 Hispanic and African American patients note that there is less need for an advance directive due to expected family roles in medical decision-making.…”

Section: Family-centered and Patient-centered Decision Makingmentioning

confidence: 99%

Communication Strategies and Cultural Issues in the Delivery of Bad News

Barclay

Blackhall

Tulsky

2007

Journal of Palliative Medicine

129

123

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Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

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Section: Family-centered and Patient-centered Decision Makingmentioning

confidence: 99%

Communication Strategies and Cultural Issues in the Delivery of Bad News

Barclay

Blackhall

Tulsky

2007

Journal of Palliative Medicine

129

123

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“…Previous studies have shown either a trend towards increased DNR prevalence in women or a lack of association of gender with DNR orders. 8,9,11,12 Gender was not significant in the third simplified model. Gender was significant in the model, which included POA and living will as independent variables, but was involved in an interaction with POA.…”

Section: Resultsmentioning

confidence: 72%

“…Some authors have shown a relationship with race, which was not found in this study, possibly due to the inclusion of confounders in past analyses. 8,9,11,12 In the multivariate analysis, patients of increasing age were significantly more likely to present with a DNR order. Previous studies have consistently demonstrated similar associations with age.…”

Section: Resultsmentioning

confidence: 96%

152: Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

Wall¹,

Hiest²

2009

Annals of Emergency Medicine

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Introduction:We conducted an epidemiologic evaluation of advance directives and do-notresuscitate (DNR) prevalence among residents of extended care facilities (ECF) presenting to the emergency department (ED). Methods:We performed a retrospective medical record review on ED patients originating from an ECF. Data were collected on age, sex, race, triage acuity, ED disposition, DNR status, power-of attorney (POA) status, and living will (LW) status. We generated descriptive statistics, and used logistic regression to evaluate predictors of DNR status.Results: A total of 754 patients over 20 months met inclusion criteria; 533 (70.7%) were white, 351 (46.6%) were male, and the median age was 66 years . DNR orders were found in 124 (16.4%, 95% CI [13.9-19.1%]) patients. In univariate analysis, there was a significant difference in DNR by gender (10.5% female vs. 6.0% male with DNR, p=0.013), race (13.4% white vs. 3.1% nonwhite with DNR, p=0.005), and age (4.0% <65 years; 2.9% 65-74 years, p=0.101; 3.3% 75-84 years, p=0.001; 6.2% >84 years, p<0.001). Using multivariate logistic regression, we found that factors associated with DNR status were gender (OR 1.477, p=0.358, note interaction term), POA status (OR 6.612, p<0.001), LW (18.032, p<0.001), age (65)(66)(67)(68)(69)(70)(71)(72)(73)(74) p=0.478;(75)(76)(77)(78)(79)(80)(81)(82)(83)(84) p=0.091, >84 years OR 5.258, P<0.001), with interactions between POA and gender (OR 0.294, P=0.016) and between POA and LW (OR 0.227, p<0.005). Secondary analysis demonstrated that DNR orders were not significantly associated with death during admission (p=0.084). Conclusion:Age, gender, POA, and LW use are predictors of ECF patient DNR use. Further, DNR presence is not a predictor of death in the hospital. [West J Emerg Med. 2015;16(7):966-973.]

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“…Several prior studies have similarly found lower survival after CPR in black patients compared to white [10,[19][20][21][22], and reasons may include more heart disease [21], less control of heart disease risk factors [21], less access to clinical care [10], receipt of lower quality care [23], a lower prevalence of ventricular fibrillation as the initial cardiac rhythm [10,24], and delayed defibrillation in the hospital [10]. Additionally, black and Hispanic patients may prefer more aggressive life-sustaining treatment than whites and therefore are more likely to receive CPR before death [25], less likely to choose DNR orders [26][27][28], and less likely to complete any advance directives [29]. Our finding that the proportion of participants receiving CPR while ventilated significantly increased from 5.3% in 1994 to 11.3 % in 2005, p value <0.001, is interesting and perhaps reflects the increasing severity of illness and the higher proportion of critically ill patients seen in hospitals throughout the US during the study period.…”

Section: Discussionmentioning

confidence: 99%

Cardiopulmonary Resuscitation Among Mechanically Ventilated Patients

Alalwan¹,

Ehlenbach²,

Young³

et al. 2012

C105. Ethics and End of Life Care in the Intensive Care Unit

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Purpose-To evaluate the outcomes, including long term survival, after CPR in mechanically ventilated patients.Methods-We analyzed Medicare data from 1994-2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated (defined by ICD-9 procedure code for intubation [96.04] Results-We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4% (95% confidence interval [CI] 18.3-18.5%). Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1% (95% CI 9.8%-10.4%), compared to 19.2% (95% CI 19.1%-19.3%) in non-ventilated patients (p<0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52% lower odds of survival (OR 0.48, 95% CI 0.46-0.49, p<0.001). Median long term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95% CI 5.3-6.8 months), compared to 19.0 months (95% CI 18.6-19.5 months) among the non-ventilated survivors (p=<0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1% were alive at one year. Conclusions-Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.

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Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit

Cited by 57 publications

References 32 publications

Communication Strategies and Cultural Issues in the Delivery of Bad News

Communication Strategies and Cultural Issues in the Delivery of Bad News

152: Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

Cardiopulmonary Resuscitation Among Mechanically Ventilated Patients

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