Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives

Abstract

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.

A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life‐Sustaining Treatment Program

“…Research suggests that the unwanted and potentially non-beneficial hospitalization of nursing facility residents is a common but often preventable event which carries significant risks to these individuals, who are susceptible to hospital-acquired infections and other adverse outcomes 26. Specific “do not hospitalize” orders, similar to the types of orders found on the POLST form, are associated with reductions in the hospitalization of nursing home residents but are rarely used 27–29. Only 14% of non-POLST users in this sample had orders reflecting preferences about hospitalization, in comparison to 97% of POLST users, and most POLST forms reflected a preference to restrict hospitalization or decline ICU care.…”

The nursing home versus the hospital as the place of dying for nursing home residents in Japan

“…The variables chosen were determined to be pertinent based on the literature [12,[16][17][18][19]24,25] and the authors' own clinical experiences. All records from the nursing home were reviewed by the first author (Takezako) to obtain information in the following domains: demography, the family decision-maker, health condition, resident and family preference for nursing home end-of-life care, presence of a full-time physician, and admission after LTCI.…”

“…According to reports [16][17][18][19] for the United States, "advanced directives" was one of the most significant factors related to nursing home death. In Japan, however, neither "advanced directives," including a "living will," nor the attorney system for medical decisions are legally binding [20].…”

Terminal Care: The Last Weeks of Life

“…Enrollment in hospice or having an advance directive, however, significantly decreases the risk of this "terminal transfer." 20,21 Institutional end-of-life care measures can be improved by hospital-based palliative care programs and nursing home hospice programs. 22,23 Likewise, institutional systematic integrated care protocols have been shown to improve symptom control during the last two days of life.…”