Toward the end of life – particularly for some frail, older individuals with chronic conditions – hospitalizations can become more frequent.
While commonly these admissions are warranted, experts say, in some cases they don’t improve comfort and can instead be stressful, expose patients to more tests and procedures and, while possibly nominally increasing the length of a person’s life, not improve their quality of life.
The research, published in March in the Journal of Post-Acute and Long-Term Care Medicine, evaluated nursing home residents in New York, including those with dementia. It found that overall, 6 percent of residents had DNH orders, and those individuals had significantly fewer hospital stays – 3 percent, compared to 6.8 percent for those without the orders – in the last 90 days. Residents with dementia who had DNH orders also had fewer hospital stays, at 2.7 percent, compared with 6.3 percent who didn’t. Put another way, the researchers noted those without DNH orders were more than twice as likely to be hospitalized.
To be sure, a Do Not Hospitalize order typically isn’t an absolute direction not to hospitalize under any circumstance – though it could be. It’s usually more nuanced, aiming to reduce hospitalizations rather than prohibit them outright. “It’s very much a misunderstood direction,” says study co-author Yuchi Young, an associate professor of health policy management and behavior at the University at Albany School of Public Health in Albany, New York. “You can give a direction, say, do not send me to the hospital except if I have profuse bleeding, or if I have severe pain,” she says. “You can have the exceptions written down in your Do Not Hospitalize order.”
Experts say it’s critical to have conversations in advance, while patients are still able to convey their wishes, particularly in cases where patients have some idea of the long-term trajectory, or stages, of their disease – like with dementia caused by Alzheimer’s disease.DNH orders can be made in many states in Physician Orders for Life-Sustaining Treatment, or portable medical documents designed to increase the likelihood that the wishes of those suffering from serious illness or frailty regarding medical treatment are followed. (These orders go by various names ranging from POLST to Medical Orders for Scope of Treatment and Physician Orders for Scope of Treatment.)
“I think it’s very important for people – especially with dementia – that they can decide their preference in the future,” says Taeko Nakashima, a visiting assistant professor at the University at Albany and adjunct assistant professor at Rutgers University, who led the research on DNH orders published in the Journal of Post-Acute and Long-Term Care Medicine.
That could also be done in a living will or advance directive. However, some research finds this approach may be less effective than having an updated order signed by a health provider in ensuring patients’ wishes regarding care they receive are followed in the event of a medical crisis.
It’s also important to be specific in outlining care preferences. “Even when advance care plans are present,” the researchers note, citing a previous study, “the directives often contain vague or inconsistent language that may lead nurses and physicians to fall back on a default pattern of always hospitalizing a patient when a problem arises.” That’s why legal and medical experts recommend in-depth, ongoing conversations between individuals, families and medical providers to plan for the future and make updates or changes to directives as needed.
“When we think about advanced care planning … whether it’s a feeding tube or whether it’s hospitalization or whether it’s resuscitation, the whole goal is that we make sure that we give people the care that is right for them, and that is aligned with their values and goals,” says Dr. Rebecca Sudore, professor of medicine in the division of geriatrics at the University of California, San Francisco, where she also directs the Innovation Center in Aging and Palliative Care. Along with making advanced care decisions explicit and specific, the reasons for a person’s end-of-life preferences should be shared with clinicians, so they’re able to advocate for treatment that aligns with that person’s values and goals.
While it’s important to be educated about all advanced care options, experts say, a DNH order may not be appropriate for many, including some nursing home residents. Often a hospital may be the optimal place for a patient to receive treatment for particular health issue; and while some nursing homes may be well-equipped to help patients manage pain, for example, others may have more limited resources and need to rely more on hospital transfers to provide adequate care.
As with any advanced care planning, determining whether to have a DNH order couldn’t be more personal – and no one decision is fitting for all. “This is a very individual decision,” Sudore says.