title: Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections.
abstract: OBJECTIVE
  To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).
  
  
  METHODS
  Prospective cohort.
  
  
  METHODS
  Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.
  
  
  METHODS
  NH residents with a LRI (n=1031).
  
  
  METHODS
  Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.
  
  
  RESULTS
  Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97).
  
  
  CONCLUSIONS
  DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.
authors.affiliation: Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, Columbia, Missouri 65212, USA. ZweigS@missouri.edu
authors.forename: Steven C
authors.initials: SC
authors.lastname: Zweig
authors.forename: Robin L
authors.initials: RL
authors.lastname: Kruse
authors.forename: Ellen F
authors.initials: EF
authors.lastname: Binder
authors.forename: Kristina L
authors.initials: KL
authors.lastname: Szafara
authors.forename: David R
authors.initials: DR
authors.lastname: Mehr
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D005260:Female; D006760:Hospitalization; D006801:Humans; D016015:Logistic Models; D008297:Male; D008923:Missouri / Q000453:epidemiology; D009735:Nursing Homes; D011446:Prospective Studies; D012141:Respiratory Tract Infections / Q000401:mortality*; D016414:Resuscitation Orders