title: Changes in Care Goals and Treatment Orders Around the Occurrence of Health Problems and Hospital Transfers in Dementia: A Prospective Study.
abstract: OBJECTIVE
  To explore changes in care goals and treatment orders around the occurrence of pneumonia and intake problems, and whether hospitalization is in line with earlier agreed-upon do-not-hospitalize orders.
  
  
  METHODS
  Data were collected as part of the Dutch End of Life in Dementia study (2007-2011), a longitudinal observational study with up to 3.5 years of follow-up.
  
  
  METHODS
  Long-term care facilities (N = 28) in the Netherlands.
  
  
  METHODS
  Newly admitted nursing home patients (N = 372) in various stages of dementia.
  
  
  METHODS
  Semiannually, physicians completed questionnaires about care goals and treatment orders, and they continuously registered episodes of pneumonia, intake problems and hospitalization. We report on changes in care goals and treatment orders during follow-up in relation to the developing of pneumonia and intake problems and on hospitalization and reasons for hospitalization.
  
  
  RESULTS
  The proportion of patients with palliative care goals and do-not-treat orders rose during follow-up, especially before death. Treatment orders most frequently referred to resuscitation and hospitalization (do-not order increased from 73% to 92%, and from 28% to 76%, respectively). The proportions of patients with a palliative care goal and do-not-treat orders were similar after developing pneumonia, but increased after intake problems. During follow-up, 46 patients were hospitalized one or more times. Hospitalization occurred despite a do-not-hospitalize order in 21% of decisions. The most frequently reported reason for hospitalization was a fracture, especially in patients with a do-not-hospitalize order.
  
  
  CONCLUSIONS
  Care plans, including global care goals (predominantly palliative care goals), are made soon after admission, and specific treatment orders are agreed upon in more detail when the condition of the patient worsens. Establishing care plans shortly after nursing home admission may help to prevent burdensome treatment.
authors.affiliation: Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Simone A
authors.identifier: http://orcid.org/0000-0001-7336-9851
authors.initials: SA
authors.lastname: Hendriks
authors.affiliation: Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Martin
authors.initials: M
authors.lastname: Smalbrugge
authors.affiliation: Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Cees M P M
authors.initials: CMPM
authors.lastname: Hertogh
authors.affiliation: Department of Primary Care and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.|Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Jenny T
authors.initials: JT
authors.lastname: van der Steen
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D003704:Dementia / Q000628:therapy*; D005260:Female; D006040:Goals; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D009426:Netherlands; D010166:Palliative Care; D011014:Pneumonia / Q000517:prevention & control*; D011446:Prospective Studies; D011795:Surveys and Questionnaires
keywords: advance care planning; care goals; dementia; hospitalization; treatment orders