title: Decisions to forgo hospitalization in advanced dementia: a nationwide study.
abstract: OBJECTIVE
  To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states.
  
  
  METHODS
  NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521).
  
  
  METHODS
  Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas).
  
  
  RESULTS
  Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations.
  
  
  CONCLUSIONS
  Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.
authors.affiliation: Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, Massachusetts 02131, USA. smitchell@hrca.harvard.edu
authors.forename: Susan L
authors.initials: SL
authors.lastname: Mitchell
authors.forename: Joan M
authors.initials: JM
authors.lastname: Teno
authors.forename: Orna
authors.initials: O
authors.lastname: Intrator
authors.forename: Zhanlian
authors.initials: Z
authors.lastname: Feng
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D006306:Health Surveys; D006707:Homes for the Aged; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009735:Nursing Homes / Q000706:statistics & numerical data; D012044:Regression Analysis; D016414:Resuscitation Orders; D013727:Terminal Care / Q000706:statistics & numerical data; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D014481:United States