title: Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey.
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.
  
  
  METHODS
  Pre- and Post-observational cohort study.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.affiliation: Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island, USA.
authors.forename: J M
authors.initials: JM
authors.lastname: Teno
authors.forename: K J
authors.initials: KJ
authors.lastname: Branco
authors.forename: V
authors.initials: V
authors.lastname: Mor
authors.forename: C D
authors.initials: CD
authors.lastname: Phillips
authors.forename: C
authors.initials: C
authors.lastname: Hawes
authors.forename: J
authors.initials: J
authors.lastname: Morris
authors.forename: B E
authors.initials: BE
authors.lastname: Fries
mesh_terms: D032722:Advance Care Planning; D016223:Advance Directives / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D015331:Cohort Studies; D005260:Female; D005440:Fluid Therapy; D005500:Follow-Up Studies; D006760:Hospitalization; D006801:Humans; D016224:Living Wills / Q000706:statistics & numerical data; D008134:Long-Term Care; D008297:Male; D008499:Medical Records; D009735:Nursing Homes / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D018529:Nutritional Support; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D010358:Patient Participation / Q000331:legislation & jurisprudence*; D016414:Resuscitation Orders; D019035:Rural Health Services; D014481:United States / Q000453:epidemiology; D019037:Urban Health Services; D028761:Withholding Treatment