NHOALOT
Nursing Homes and Life-sustaining Options for Treatment
Funded by: Hartford/Jahnigan Center of Excellence Junior Faculty Stipend
Project Period: 7/03 - 6/05
Abstract
Objective: To understand the meaning of do not resuscitate (DNR) orders
in nursing homes and their effect on the care of nursing home residents using both quantitative
and qualitative methods. The quantitative components of the study will determine: 1) how
physician/nurse practitioner visit and hospitalization rates differ for residents with DNR
orders who experience clinical decline compared to those without DNR orders who experience
clinical decline; and 2) the proportion of nursing home residents with DNR orders who desire
treatment limitations beyond cardiopulmonary resuscitation (CPR). The qualitative component
of the study will involve in-depth interviews with nurses assigned to residents at the time of
hospitalization or death.
Methods: Chart Abstraction:
The Acute Clinical Decline instrument is adapted from the Nursing Home Case-Mix and Quality
Demonstration Chart Review Instrument used in prior studies conducted at the University of
Colorado on processes of care in nursing homes. The PI and a trained research nurse conduct
structured record reviews using this instrument. Acute clinical decline is defined as two or
more abnormal vital signs or notes indicating delirium in the preceding 24 hours that were
associated with a call to the practitioner. If either delirium or two or more abnormal vital
signs are noted and a call was placed to the practitioner as documented in the nursing notes
regarding these abnormalities, the Acute Clinical Decline data collection instrument is
utilized.
The Nursing Home Resident Clinical Scenario Questionnaire, developed by the PI,
includes education about life-sustaining treatments followed by close-ended questions regarding
previous discussions about advance care planning, and treatment preferences in various medical
scenarios. For each scenario, the resident is asked to report his or her preferences for 1)
visitation by a practitioner in the nursing home facility, 2) hospitalization, 3) CPR, 4)
mechanical ventilation, 5) artificial hydration/nutrition and/or 6) hospice care.
Qualitative Nurse Interviews are conducted to elicit nurses’ decision-making
processes when residents experience acute decline. The purpose is to explore, describe and
understand patterns, social processes, attitudes, and beliefs regarding the acute clinical
decline in nursing homes. All registered nurses or licensed practical nurses that are
assigned to a resident at the time the resident experiences clinical decline are interviewed
individually and tape-recorded.
Current Project Status: Currently, 79 chart abstractions and 33
resident interviews have been performed. Three nurses have been interviewed for the
qualitative portion of the investigation. The resident questionnaires demonstrate that
residents have different preferences for life-sustaining treatment depending on the clinical
scenario and preferences indicated on the chart frequently do not reflect these preferences.
The nurse interviews indicate that DNR orders are interpreted by nursing home nurses as an
indicator that residents desire limited care overall, not just the limitation of CPR. Data
collection is expected to be complete in July 2005.
Key Staff: Levy, Faut, Bemski