Changes in advance care planning in nursing homes before and after the patient self-determination act: Report of a 10-state survey

Joan Teno, Kenneth J. Branco, Vincent Mor, Charles D. Phillips, Catherine Hawes, John Morris, Brant E. Fries

Research output: Contribution to journalArticle

112 Citations (Scopus)

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 longterm 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.

Original languageEnglish (US)
Pages (from-to)939-944
Number of pages6
JournalJournal of the American Geriatrics Society
Volume45
Issue number8
DOIs
StatePublished - Jan 1 1997
Externally publishedYes

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Patient Self-Determination Act
Advance Care Planning
Resuscitation Orders
Nursing Homes
Living Wills
Documentation
Advance Directives
Lawyers
Cardiopulmonary Resuscitation
Patient Rights
Medical Records
Observational Studies
Surveys and Questionnaires
Decision Making
Hospitalization
Cohort Studies

ASJC Scopus subject areas

  • Geriatrics and Gerontology

Cite this

Changes in advance care planning in nursing homes before and after the patient self-determination act : Report of a 10-state survey. / Teno, Joan; Branco, Kenneth J.; Mor, Vincent; Phillips, Charles D.; Hawes, Catherine; Morris, John; Fries, Brant E.

In: Journal of the American Geriatrics Society, Vol. 45, No. 8, 01.01.1997, p. 939-944.

Research output: Contribution to journalArticle

Teno, Joan ; Branco, Kenneth J. ; Mor, Vincent ; Phillips, Charles D. ; Hawes, Catherine ; Morris, John ; Fries, Brant E. / Changes in advance care planning in nursing homes before and after the patient self-determination act : Report of a 10-state survey. In: Journal of the American Geriatrics Society. 1997 ; Vol. 45, No. 8. pp. 939-944.
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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 longterm 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.",
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