Advance Directives and Care Received by Older Nursing Home Residents.
BACKGROUND
Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD).


OBJECTIVE
We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT), or both. Design/participants/measurements: A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. The ADs were divided as follows: (1) comfort oriented: comfort measures only, no hospital transfer; (2) palliative oriented: comfort focused, allowing hospital transfer (except intensive care unit), antibiotic use, but no cardiopulmonary resuscitation; (3) usual care: full code, no limitations to care. We calculated incidences for these outcomes.


RESULTS
Seventy-eight (87%) residents had ADs: 18 (23%) comfort oriented, 32 (41%) palliative oriented, and 28 (36%) usual care. The groups did not differ regarding demographics, comorbidity, function, device presence, or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (Incidence rate [IR] = 15.6/1000 follow-up days vs IR = 8.8/1000 follow-up days, Incident rate ratio [IRR] 0.6 [95% confidence interval, CI, 0.3 -1.1], P value .09) but received fewer antibiotics (IR = 18.9/1000 follow-up days vs IR = 7.5/1000 follow-up days, IRR 0.4 [95% CI, 0.2-0.8], P value .005).


CONCLUSIONS
Nursing home residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual-care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.
1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA.
Erika R
ER
Manu
1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA.
Lona
L
Mody
1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA.
Sara E
SE
McNamara
1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA.
Caroline A
CA
Vitale
D024362:Advance Directive Adherence / Q000706:statistics & numerical data*; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data; D004750:Enteral Nutrition / Q000706:statistics & numerical data; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008824:Michigan; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010166:Palliative Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D014546:Urinary Catheterization / Q000706:statistics & numerical data
D000900:Anti-Bacterial Agents
advance directives; care processes; feeding tube; nursing home; older adults; urinary catheter