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Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey.
J Am Geriatr Soc. 1997 Aug; 45(8):939-44.JA

Abstract

OBJECTIVE

The Patient Self-Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision-making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states.

DESIGN

Pre- and Post-observational cohort study.

PATIENTS

Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six-month follow-up was obtained at both time periods.

MAIN OUTCOME MEASURES

Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a "Do Not Resuscitate" (DNR) order, a "Do Not Hospitalize" (DNH) order, or an order to forgo artificial nutrition or hospitalization.

RESULTS

The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990.

CONCLUSION

With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation.

Authors+Show Affiliations

Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

9256845

Citation

Teno, J M., et al. "Changes in Advance Care Planning in Nursing Homes Before and After the Patient Self-Determination Act: Report of a 10-state Survey." Journal of the American Geriatrics Society, vol. 45, no. 8, 1997, pp. 939-44.
Teno JM, Branco KJ, Mor V, et al. Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey. J Am Geriatr Soc. 1997;45(8):939-44.
Teno, J. M., Branco, K. J., Mor, V., Phillips, C. D., Hawes, C., Morris, J., & Fries, B. E. (1997). Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey. Journal of the American Geriatrics Society, 45(8), 939-44.
Teno JM, et al. Changes in Advance Care Planning in Nursing Homes Before and After the Patient Self-Determination Act: Report of a 10-state Survey. J Am Geriatr Soc. 1997;45(8):939-44. PubMed PMID: 9256845.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey. AU - Teno,J M, AU - Branco,K J, AU - Mor,V, AU - Phillips,C D, AU - Hawes,C, AU - Morris,J, AU - Fries,B E, PY - 1997/8/1/pubmed PY - 1997/8/1/medline PY - 1997/8/1/entrez KW - Death and Euthanasia KW - Empirical Approach KW - Legal Approach SP - 939 EP - 44 JF - Journal of the American Geriatrics Society JO - J Am Geriatr Soc VL - 45 IS - 8 N2 - OBJECTIVE: The Patient Self-Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision-making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states. DESIGN: Pre- and Post-observational cohort study. PATIENTS: Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six-month follow-up was obtained at both time periods. MAIN OUTCOME MEASURES: Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a "Do Not Resuscitate" (DNR) order, a "Do Not Hospitalize" (DNH) order, or an order to forgo artificial nutrition or hospitalization. RESULTS: The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990. CONCLUSION: With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation. SN - 0002-8614 UR - https://www.unboundmedicine.com/medline/citation/9256845/Changes_in_advance_care_planning_in_nursing_homes_before_and_after_the_patient_Self_Determination_Act:_report_of_a_10_state_survey_ L2 - https://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0002-8614&date=1997&volume=45&issue=8&spage=939 DB - PRIME DP - Unbound Medicine ER -