Advance orders to limit therapy in 67 long-term care facilities in Finland.
OBJECTIVE
To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.


METHODS
Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.


RESULTS
Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.


CONCLUSIONS
We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.
Laakkonen
Marja-Liisa
ML
Helsinki City Hospital Koskela, P.O. Box 6410, FIN-00099 Helsinki, Finland. marja-liisa.laakkonen@hel.fi
Finne-Soveri
U Harriet
UH
Noro
Anja
A
Tilvis
Reijo S
RS
Pitkala
Kaisu H
KH
D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D040561:Assisted Living Facilities; D005260:Female; D005387:Finland; D006760:Hospitalization; D006763:Hospitals, Chronic Disease; D006801:Humans; D016224:Living Wills; D008134:Long-Term Care; D008297:Male; D009735:Nursing Homes; D016414:Resuscitation Orders