Hospital and medical care use by nursing home patients: the effect of patient care plans

Although there has been increasing attention to the ethical and legal issues involved in the patient's right to have treatment or hospitalization withheld, there have been few empirical evaluations of programs designed to accomplish that end. Over a 7-year period, a medical group cared for 110 patients in a skilled nursing facility. After assessing the patients' wishes and the opinions of the personal physicians and nurses, care plans were made specifying whether each one was to receive maximum, intermediate, or comfort care. The hospitalization rate was found to be 79% lower for the patients receiving comfort care. Multiple admissions were unusual. Those patients made no use of outpatient consultants or major diagnostic procedures and had only 14% as many roentgenograms as the patients receiving maximum care. Whereas acute medical and surgical problems and related physician visits were more frequent for the comfort care groups, specific treatment of those problems was withheld far more often. Mortality was twice as great among the comfort care patients, and nearly all of these deaths occurred in the nursing home. It was concluded that the patient's decision to avoid active management can be honored by specific patient plans carefully communicated to all physicians sharing responsibility for that person's care.