Environmental contexts of ultimate decisions: why White nursing home residents are twice as likely as African American residents to have an advance directive

OBJECTIVES: The purpose of this study was to determine the extent to which observed differences between White and African American nursing home residents in having an advance directive are attributable to differences between the groups in personal characteristics, the organizational environment of the nursing home, and the geographical environment of the counties in which the nursing homes are located. METHODS: By using the Medical Expenditure Panel Survey Nursing Home Component matched with county-level measures from the Area Resource File, we modeled the probability of having an advance directive as a function of nursing home resident, facility, and county characteristics for African American and White residents. RESULTS: The probability of having an advance directive was 27.0% for African American residents and 63.6% for White residents. Nearly half of this 36.6 percentage point gap could be explained by group differences in personal, facility, and county characteristics. DISCUSSION: County characteristics play a more prominent role than do personal or facility measures in explaining the observed ethnic gap in the prevalence of advance directives. Additional studies should focus further on geographic, health status, and attitudinal variations among nursing home residents that may account for the remaining ethnic difference in the prevalence of advance directives among nursing home residents.     

The effect of a social work intervention to enhance advance care planning documentation in the nursing home

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.     

Recent trends in advance directives at nursing home admission and one year after admission

PURPOSE: Advance directives are important planning and decision-making tools for individuals in nursing homes. DESIGN AND METHODS: By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission. RESULTS: The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type. IMPLICATIONS: The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time.     

Attitudes toward discussing life-sustaining treatments in extended care facility patients.

OBJECTIVE: To determine nursing home residents' attitudes toward discussing life-sustaining treatment plans with their physicians and the factors associated with these attitudes. DESIGN: Random-sample, interviewer-administered survey. SETTING: Forty-one nursing homes in which some residents were cared for by house-staff physicians of the Hennepin County (Minnesota) Medical Center Extended Care Department. PATIENTS: Random sample of 150 nursing home residents receiving primary care from Extended Care Department physicians, 131 (87%) of whom completed the interview. RESULTS: Older individuals were less likely to have spoken with physicians and family members about treatment plans (p < 0.05), and to have felt that they had more say than necessary in their treatment (P < 0.05). Only 19 (14.5%) residents had formal treatment plan discussions about limiting life-sustaining treatment. Although perceived current health status did not differ between residents with and without treatment plans, those residents who had discussions about advance directives were more likely to report health improvement over the past 6 months (P < 0.05). Residents with formal advance directives were, on average, 8.4 years younger than those without them (P < 0.05). CONCLUSIONS: Younger patients are more likely to have had discussions about life-sustaining treatment and are also more frequently involved in plan development. Preferences for level of involvement should be considered during advance directive planning, and it should be recognized that these preferences may vary with age. Future research should evaluate whether this age relationship is a true age or a cohort effect.     

Advance care planning in nursing homes: correlates of capacity and possession of advance directives

PURPOSE: The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. DESIGN AND METHODS: The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors. RESULTS: Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged. IMPLICATIONS: Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.     

Discussion as a Factor in Racial Disparity in Advance Directive Completion at Nursing Home Admission

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P -values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives ( P <.001), and they ( P <.001) and their family members ( P <.001) were less likely than whites to have discussed treatment restrictions with healthcare providers. Logistic regression models indicated that disparity in treatment restrictions narrowed when these discussions occurred. Significant others of black residents were more likely than those of white residents to consider further discussion helpful ( P <.001), especially with physicians. Racial disparity in treatment restrictions may be due in part to a difference in discussion with healthcare providers; increasing discussion may narrow this disparity.     

Nursing home resident use of care directives.

BACKGROUND: The Patient Self-Determination Act of 1991 requires that nursing homes reimbursed by Medicare or Medicaid inform all residents upon admission of their rights to enact care directives in the event of terminal illness. This study investigated the relationship between care directive use and resident functional status. METHODS: We analyzed a version of the Minimum Data Set (MDS+) from a single state. We selected residents who were admitted to a nursing home in the first half of 1993 and followed them in the nursing home through the end of 1994. We created logistic models to examine independent correlates associated with having an advance directive or a do-not-resuscitate (DNR) order on admission. We then created similar logistic models to examine independent correlates associated with writing an advance directive or DNR order subsequent to admission. RESULTS: Of the 2,780 residents, 11% (292) had advance directives and 17% (466) had DNR orders upon admission. Of those without care directives upon admission, 6% (143) subsequently had an advance directive and 15% (339) subsequently had a DNR order. Cross-sectionally, older individuals and whites were more likely to have a care directive. Having poor cognitive and physical function was associated with having a DNR order upon admission. Longitudinally, longer stayers and whites were more likely to have an advance directive. Residents who lost physical function were more likely to have an advance directive and those who lost cognitive function were more likely to have a DNR order. CONCLUSIONS: Care directive use is influenced by a number of sociodemographic and functional characteristics.     

Outcomes of managed care of dually eligible older persons

PURPOSE: To assess changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options (MSHO), a managed care program for older persons eligible for both Medicare and Medicaid. DESIGN AND METHODS: We used two sets of matched controls for MSHO enrollees and their families and matched controls living in the community and in nursing homes: Persons in the same county who were eligible to enroll but did not enroll in MSHO and persons in other metropolitan areas where MSHO is not available. For the community sample, we used questionnaires to measure functional status (activities of daily living), pain, unmet care needs, satisfaction, and caregiver burden. Approximately 2 years after the first survey, we resurveyed respondents who lived in the community at the time of the first survey. For the nursing home residents, we used annual assessments to calculate case mix to compare changes in functional levels over time. RESULTS: There were few significant differences in change over time between the MSHO sample and the two control groups. Out-of-area controls showed greater increases in pain but in-area controls showed less interference from pain. Compared with out-of-area controls, MSHO clients showed greater increase in homemaker use, meals on wheels, and outpatient rehabilitation. Compared with in-area controls, they showed more use of meals on wheels and less help from family with household tasks. There were few differences in satisfaction, but the MSHO families showed significantly lower burden than controls on five items. IMPLICATIONS: The analyses show only modest evidence of benefit from MSHO compared with the two control groups. The model represented by MSHO does not appear to generate substantial differences in outcomes across function, satisfaction, and caregiver burden.     

Medical management decisions in nursing home patients. Principles and policy recommendations

The ethical principles of medical decision making are inherently the same for nursing home residents, who represent an increasingly large segment of the population, as they are for other adult patients. In practice, however, a number of considerations require specialized application of these principles in nursing homes. Notably, a large proportion of nursing home patients are at high risk for morbid and mortal events yet are incapable of expressing medical management preferences due to dementia and confusion. Policies and procedures regarding medical decisions for nursing home patients are needed. We present and discuss a policy for patient care in nursing homes based on recommendations of a national biomedical ethics committee. This policy, which may be adapted for use in specific institutions, explicitly discusses the principles of care and their application in nursing homes. It also encourages prospective decision making and provides advance care directives for patients making and provides advance care directives for patients and their decision-making surrogates to do so.     

Pneumonia in nursing home residents: factors associated with in-home care of EverCare enrollees

OBJECTIVES: To identify determinants of whether nursing home (NH) residents enrolled in EverCare were admitted to in-home intensive service days (ISDs) rather than a hospital when they were thought to have pneumonia. DESIGN: Retrospective cross-sectional. SETTING: EverCare operations in five metropolitan areas. PARTICIPANTS: EverCare enrollees admitted to ISDs or a hospital for suspected pneumonia in 2002. MEASUREMENTS: Member, nurse practitioner, physician, and NH characteristics extracted from EverCare's administrative data and Online Survey Certification and Reporting NH data. RESULTS: Multivariable logistic regression indicated that admission to ISDs (65% of cases) was positively associated with age (odds ratio (OR)=1.04. 95% confidence interval (CI) 1.03-1.04), advance directives not to hospitalize (OR=2.88, 95% CI=1.76-4.72), or perform cardiopulmonary resuscitation, 3.09 (2.44-3.91), and hours worked by the NH's registered nurses (OR=4.34, 95% CI=1.74-10.8). Admission to ISD was less likely on weekends (OR=0.30, 95% CI=0.21-0.43), when residents had renal insufficiency (OR=0.61, 95% CI=0.49-0.76), and when the resident was covered by Medicaid (OR 0.87, 95% CI=0.82-0.93). CONCLUSION: Exploration of ways to extend services to weekends, increased availability of registered nurse staff, attention to advance directives, and a better understanding of the role of Medicaid might increase the likelihood of caring for EverCare enrollees with suspected pneumonia in their NH.     

Home from home: residents' opinions of nursing homes and long-stay wards

OBJECTIVE: To compare the levels of satisfaction expressed by residents of nursing homes with those of patients in geriatric long-stay wards. DESIGN: A structured satisfaction questionnaire containing 37 closed and two open questions was used to elicit responses from residents of nursing homes in the former South West Thames Regional Health Authority area. This was compared with a similar survey using the same questionnaire among patients in geriatric long-stay wards surveyed in 1989. SETTING: respondents came from a sample of nursing homes chosen to be representative of both size and geographical location. Nursing homes were stratified by number of beds (1-19, 20-29, 30+) and clustered by location (to reflect the urban, semi-rural and coastal nature of the region). SUBJECTS: A random sample was drawn from each grouping (size and location) to yield a resident sample of 850 in 36 nursing homes. This figure was similar to the number of patients (808) in geriatric long-staywards surveyed in 1989. All eligible nursing home patients were assessed for physical dependency. Mental confusion was ascertained by the Abbreviated Mental Test Score (AMTS). Patients who scored three or less on the AMTS (indicative of severe confusion) or had dysphasia, profound deafness or concurrent serious illness were excluded from further study. RESULTS: 377 nursing home residents were able to complete the questionnaire and their answers were compared with those of 291 long-stay geriatric patients. The responses to the five themes--relations with staff, autonomy, amenities, privacy and social environment-show some minor differences between the two groups but what is more noticeable is the similarity of their views. This is important as much social policy assumes that the more 'homely' atmosphere of the nursing home should elicit higher levels of satisfaction than the 'institutional' setting of the hospital ward. CONCLUSION: We conclude that the difference between nursing homes and hospital wards in terms of their institutionalizing capacities is not as profound as policy-makers believe.     

Nursing facility compliance with do-not-hospitalize orders

PURPOSE: This study sought to determine whether nursing homes comply with residents' do-not-hospitalize (DNH) orders prohibiting inpatient hospitalization. DESIGN AND METHODS: With the use of data from the nationally representative 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multivariate logistic regression model was developed. RESULTS: Three percent of residents had DNH orders. These residents were half as likely to be hospitalized. Residents in not-for-profit or public facilities were less likely to be hospitalized than those in for-profit homes. Hospitalization was more likely among men, racial or ethnic minorities, those with more diagnosed health conditions, and those in facilities in the South compared with those in the Midwest. Hospitalized residents with DNH orders had no limitations of activities of daily living, were not located in hospital-based nursing homes, were less likely to be in a for-profit facility, and were sicker than nonhospitalized residents with DNH orders. IMPLICATIONS: Improved education regarding advance directives, particularly DNH orders, is necessary for health care practitioners and patients. More consistent and rigorous policies should be implemented in nursing facilities.     

Wishes of nursing home residents concerning their life situation--results of a qualitative study

OBJECTIVE: This study examined the wishes of nursing home residents concerning their life situation in the nursing home. METHODS: Using a qualitative study design, a representative sample of nursing home residents (n = 1656) of 24 nursing homes in a city situated in the eastern part of Germany were interviewed. RESULTS: The analyses of residents' wishes lead to major domains such as the quality of care, interpersonal contact, architecture and organization of the house, diversification, financial support, as well as themes like health and death and the wish to leave the nursing home. Residents focus on an individualized approach to care. CONCLUSIONS: Nursing home residents' views support the need to improve the psychological and social aspects of the quality of care. Implications of and consequences for the organization of care and concepts of nursing are discussed.     

Disruptive Behaviors in Veterans Affairs Nursing Home Residents: How Different Are Residents with Serious Mental Illness?

OBJECTIVES: To determine the prevalence and correlates of behavior problems of residents of Veterans Affairs (VA) nursing homes and to compare residents with serious mental illness (SMI) with other resident groups. DESIGN: This study combined cross-sectional resident assessments with administrative data for all residents in VA nursing homes. Multivariate ordinal logistic regression was used to evaluate associations between resident characteristics and problem behaviors. SETTING: Nursing home care units in the VA healthcare system. PARTICIPANTS: A total of 9,618 nursing home residents assessed as part of the VA's April 2001 national resident census. MEASUREMENTS: The Patient Assessment Instrument assessed each resident's verbally disruptive, physically aggressive, and socially inappropriate behaviors in the prior 4 weeks. Functional limitations in eating, mobility, toileting, and transfer were assessed. Diagnoses were evaluated for the stay and up to 6 months before assessment. RESULTS: Almost one-fifth (17.9%) of residents received a diagnosis of SMI. Residents with SMI or dementia had greater behavior problems than residents with neither condition. Residents with SMI (and without dementia) exhibited more verbal disruption than residents with dementia (and without SMI), but the two subgroups did not differ in physically aggressive or socially inappropriate behavior. CONCLUSION: Many VA nursing home residents have SMI. Their level of behavior problems is comparable with that of residents with dementia. Clinical practice and nursing home staff training must encompass geriatric mental health and behavior management to meet the needs of residents with SMI.     

Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.

OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.     

Mental health services and the mortality of nursing home residents

This article examines the impact of mental health services on the mortality rate for mentally ill nursing home residents. Previous research has documented the unmet need for mental health services among nursing home residents. Some research using small data sets has indicated patient benefits from treatment. This article examines the issue using data from the nationally representative National Nursing Home Survey. In a series of multivariate logistic regressions, treatment for mental illness provided by either general practice physicians or by mental health specialists appears to have few impacts on mortality. A statistically significant treatment effect is found only for residents with schizophrenia, other psychoses, or anxiety disorders when treated by mental health specialists. The results are discussed with reference to ongoing reforms for mental health care in nursing homes.     

The employment of nurse practitioners and physician assistants in U.S. nursing homes

PURPOSE: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. DESIGN AND METHODS: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. RESULTS: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). IMPLICATIONS: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.