title: Do-Not-Hospitalize Orders in Nursing Homes: "Call the Family Instead of Calling the Ambulance".
abstract: OBJECTIVE
  To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place.
  
  
  METHODS
  Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014.
  
  
  METHODS
  Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010.
  
  
  METHODS
  Nursing facility staff members (N = 31).
  
  
  METHODS
  A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes.
  
  
  RESULTS
  DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred.
  
  
  CONCLUSIONS
  In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.
authors.affiliation: Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Cohen
authors.affiliation: Division of Acute Care/Health Systems, Yale School of Nursing, Yale University, New Haven, Connecticut.
authors.forename: M Tish
authors.initials: MT
authors.lastname: Knobf
authors.affiliation: Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.|Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology*; D003237:Connecticut; D005190:Family / Q000523:psychology*; D005260:Female; D066296:Grounded Theory; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes / Q000706:statistics & numerical data*; D036301:Qualitative Research; D013727:Terminal Care
keywords: advance directives; clinical decision-making; hospitalization; nursing homes; qualitative research