An order not to hospitalize

A researcher discusses a study on this type of advance directive.

Hospitalists are keen on reducing unnecessary medical care, but reducing unwanted care involves forethought. This is where do-not-hospitalize (DNH) orders can help. With this type of advance directive, patients indicate their desires for acute care services (or lack thereof) before a medical emergency happens.

To quantify the prevalence of DNH orders, Taeko Nakashima, PhD, and colleagues examined a population of more than 43,000 nursing home residents in New York. Overall, 61% had do-not-resuscitate orders, 12% had feeding restrictions, and only 6% had DNH orders, according to results published in the May 2017 Journal of Post-Acute and Long-Term Care Medicine.

Dr. Nakashima, a visiting assistant professor at the State University of New York at Albany and adjunct assistant professor at Rutgers University, recently spoke with ACP Hospitalist about DNH orders.

Q: What led you to study this issue?

A: From our experiences and a review of the literature, we feel that the elderly tend to receive undesired hospital transfers. We wondered if DNH orders might possibly reduce undesired hospital transfers. In addition, I have been interested in how health care professionals can protect people with dementia, enabling them to live in dignity for a long time.

Q: What were your most surprising findings?

A: Some of the results were exactly as we expected them. Our findings indicate that residents without DNH orders were more than twice as likely to be hospitalized. Approximately 36% of nursing home residents had no advance directives at all. This result indicates that advance directives are underutilized among older adults in New York State nursing homes, even though federal law has further required that people (or a surrogate if the person is incapacitated) be advised of their right to complete an advance directive at the time of admission as a resident to nursing homes since 1995.

Q: What are the benefits of DNH orders in the nursing home population, particularly in patients with dementia?

A: The benefit of DNH orders is the reduction of unnecessary and undesired hospitalizations. Hospital transfers for people with advanced dementia have limited usefulness because people with dementia often receive burdensome and costly interventions with limited benefit, such as tube feeding. In addition, these transfers can be anxiety-provoking because of the stress of unfamiliar surroundings. Therefore, we think reducing undesired hospitalization using advance directives, such as DNH orders, is important for nursing home residents with dementia.

Q: In your study, having DNH orders (versus not having them) reduced hospital stays from 6.8% to 3.0% and ED visits from 3.6% to 2.8%. What are the implications?

A: The percentage of reduction may be small, but we think that it has significant clinical and policy implications. As we mentioned in our article, the majority of hospital admissions are necessary, but many are not. [One study found that] almost 50% of hospital admissions for nursing home residents in their last year of life were for potentially avoidable diagnoses, costing Medicare $1 billion.

In 2012, there were 36.5 million hospital admissions, with an average length of stay of 4.5 days and an average cost of $10,400 per stay. Our study results indicate that residents without DNH orders had a 3.8% greater number of hospital transfers than those with DNH orders. If we apply this to 1.4 million nursing home residents [in 2014], this would equate to 53,200 hospital transfers that may have been averted per year had all residents filled out DNH orders and [had] their wishes honored. This hospital-transfer reduction would translate to about $553 million in cost savings.

Q: Who is the ideal candidate for DNH orders?

A: We think it is better that everyone think about their [personal] end-of-life wishes. However, a person who is seriously ill or frail is the ideal candidate. It is difficult for caregivers, surrogates, and care providers who take care of people with dementia to make decisions without DNH orders. DNH orders should be made when the person with dementia still has legal and cognitive capacity . . . [and] should be reviewed periodically or after a change in medical status.

Q: Why do you think DNH orders were so much less common than other advance directives in your study population?

A: We think that many people consider DNH orders [to mean] “do not treat,” but that is not accurate because the nursing home staff do the most they can do for residents in the nursing home. Therefore, we think it is important that health care providers [explain] the meaning of DNH orders to residents or surrogates . . . . Residents can have exceptions written down in [their] DNH order: For example, “Do not send me to the hospital unless I have severe pain.”

Q: Is there anything physicians can do during hospitalization to help older patients with this issue?

A: Preparing DNH orders requires collaborative efforts and thorough discussion among the resident, surrogate, and the attending physician about the goals of the resident, the resident's prognosis, and treatment options. Another article indicates that DNH orders are less likely to be used if physicians are not closely involved with the patient or do not understand DNH orders well. It is very helpful that a physician provides information on the patient's prognosis thoughtfully as his or her disease progresses and physical or mental function deteriorates.