Jordan Ellis
Do-not-hospitalize (DNH) orders are medical orders written by physicians that apply to a nursing home resident's current health status. They are used to indicate that the resident does not wish to be hospitalized and would prefer to receive end-of-life care in the nursing home. DNH orders are intended to reduce potentially burdensome hospitalizations, particularly in the last days of life, and have been shown to decrease the likelihood of hospitalization. However, they are infrequently used, with only a small percentage of nursing home residents having these orders in place. There is ongoing research and debate about how DNH orders are interpreted and applied in practice, and how they can be effectively implemented to respect the wishes of residents and reduce unnecessary transfers to hospitals.
| Characteristics | Values |
|---|---|
| Purpose | To reduce the number of hospitalizations near the end of life, which can be burdensome and distressing for patients |
| Prevalence | Varies across facilities, with some studies reporting 12-23% of facilities having DNH policies in place and 3-7% of residents having DNH orders |
| Impact | Residents with DNH orders are less likely to be hospitalized, but it is not an absolute prohibition as some are still hospitalized |
| Interpretation | Staff interpretations vary, with some understanding it as a flexible guideline with exceptions rather than a strict rule |
| Communication | In-the-moment discussions about hospitalization are necessary even with a DNH order, and preparing residents and families to make informed decisions is key |
| Barriers | Overly optimistic prognosis, lack of knowledge about DNH orders, and uncertainty about prognosis may hinder the initiation of DNH orders |
| Facilitators | Understanding of end-of-life care, recognition of advanced dementia as a terminal illness, and consideration of patient wishes can facilitate DNH orders |
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What You'll Learn
- DNH orders are infrequently used, with only 7% of nursing home residents having them
- DNH orders can reduce burdensome hospital transfers for patients at the end of life
- Nursing home staff perspectives on DNH orders and end-of-life care
- DNH orders are medical orders written by physicians based on a patient's current health status
- Studies have found that 25% of nursing home patients received care that was inconsistent with their wishes
DNH orders are infrequently used, with only 7% of nursing home residents having them
Do-Not-Hospitalize (DNH) orders are medical orders written by physicians that apply to a resident's current health status. They are used to indicate that the resident or responsible party does not want to be hospitalized in the event of a medical emergency. DNH orders are different from Do-Not-Resuscitate (DNR) orders, which are more widely recognized and understood.
There are several possible reasons for the low usage of DNH orders. One factor could be a lack of knowledge or understanding about DNH orders among healthcare practitioners and patients. Uncertainty about prognosis, clinical uncertainty, and a physician's failure to communicate the prognosis can also play a role. Additionally, there may be institution- and family-related barriers that hinder the wider adoption of DNH orders.
The effectiveness of DNH orders in reducing hospitalizations is supported by studies showing that residents with DNH orders are less likely to be hospitalized near the end of life. However, it is important to note that DNH orders do not completely prevent hospitalizations, as more than 10% of patients with DNH orders are still hospitalized each year.
To address the low usage of DNH orders and potentially reduce burdensome hospitalizations, there is a need for improved education and consistent policies regarding advance directives, including DNH orders. This includes enhancing understanding among healthcare practitioners, patients, and their families about the options available and how DNH orders are interpreted and applied in nursing homes.
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DNH orders can reduce burdensome hospital transfers for patients at the end of life
Do-Not-Hospitalize (DNH) orders can help reduce burdensome hospital transfers for patients at the end of their lives. DNH orders are medical orders written by physicians that apply to the patient's current health status. They are used to express a patient's preference to forego further hospitalization and translate that preference into a medical order.
DNH orders are particularly relevant for nursing home residents, as more than a third of them are hospitalized in the last 30 days of their lives. Many of these hospitalizations may be unnecessary, as they occur for care that does little to change the course of illness or improve quality of life. Instead, they may cause iatrogenic harm and distress to patients.
Studies have shown that residents with DNH orders are less likely to be hospitalized near the end of life. However, DNH orders are rarely used, with only about 7% of nursing home residents having these orders in place. This may be due to a lack of understanding about DNH orders among healthcare practitioners and patients, as well as uncertainty about prognosis.
To reduce potentially burdensome hospital transfers, it is important to focus on eliciting residents' and their families' preferences in advance and preparing them to make informed decisions about hospitalization when the time comes. This includes improved education regarding advance directives and more consistent and rigorous policies in nursing facilities. Additionally, factors such as communication between staff and families, institutional processes, and staff attitudes towards DNH orders play a role in how these orders are interpreted and applied in nursing homes.
In conclusion, DNH orders have the potential to reduce burdensome hospital transfers for patients at the end of their lives, but their effectiveness depends on how they are interpreted and used in nursing homes. More widespread adoption and improved understanding of DNH orders may help to reduce unnecessary hospitalizations, particularly for those at the end of life.
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Nursing home staff perspectives on DNH orders and end-of-life care
Nursing home staff have varying perspectives on Do-Not-Hospitalize (DNH) orders and end-of-life care. While DNH orders are intended to reduce unnecessary hospitalizations, particularly near the end of life, they are infrequently used, with only around 7% of nursing home residents having these orders in place. This underutilization may be due to a lack of understanding among healthcare proxies (HCPs) and other nursing home staff about how DNH orders are interpreted and applied in practice.
Some staff members view DNH orders as a "sweeping injunction" or a "death sentence", while others see them as flexible directives with various exceptions. A study of nursing home patients and their families found that 25% of patients received care that was inconsistent with their previously expressed wishes, highlighting the complexity of honoring DNH orders.
To address this, nursing homes should focus on improving communication between staff and families, as well as staff education on advance directives and end-of-life care. In-the-moment discussions about hospitalization are still necessary, even with a DNH order, to ensure that residents' wishes are respected and that they receive the most appropriate care.
From the staff's perspective, several factors influence the interpretation and application of DNH orders. These include the resident's current health status, sociodemographic factors, and facility characteristics. For example, residents in for-profit facilities are more likely to be hospitalized, and DNH orders are less common among non-white residents. Additionally, staff members' experiences in the healthcare field shape their understanding of treatment options within the nursing home and the potential disadvantages of hospital transfers.
Prognostic information and understanding the life-limiting nature of certain illnesses, such as advanced dementia, also play a crucial role in staff decision-making regarding DNH orders. However, uncertainty about prognosis, whether due to clinical factors or a lack of communication from physicians, can be a barrier to initiating these orders.
In conclusion, nursing home staff perspectives on DNH orders and end-of-life care are varied and complex. While DNH orders have the potential to reduce burdensome hospitalizations, particularly at the end of life, their effective implementation requires a nuanced understanding of residents' wishes, prognoses, and the interpretation of DNH orders within the context of individual facilities.
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DNH orders are medical orders written by physicians based on a patient's current health status
Do-Not-Hospitalize (DNH) orders are medical orders written by physicians based on a patient's current health status. They are used in nursing homes to reduce the number of hospitalizations, particularly in the last month of a patient's life. These orders are important as they translate a patient's preference to forego further hospitalization into a medical order.
DNH orders are underutilized, with only 7% of nursing home residents having them. This is despite evidence that they work—residents with DNH orders are less likely to be hospitalized. This figure varies depending on the type of facility, with for-profit nursing facilities having fewer DNH orders. One study found that 80% of respondents indicated that physicians in their facilities wrote DNH orders, but 77% believed the number of DNH orders was too few. This discrepancy has been attributed to overly optimistic prognoses and a lack of knowledge about DNH orders.
There is also a lack of understanding about how DNH orders are interpreted and used in nursing homes. While some experts view them as a "sweeping injunction" or "death sentence," others argue that they are not absolute, pointing to evidence that more than 10% of patients with DNH orders are still hospitalized each year. In-depth interviews with nursing facility staff revealed that they did not interpret DNH orders literally and understood them to have a variety of exceptions.
DNH orders are especially relevant for patients with advanced dementia, who make up a significant proportion of nursing home residents. Studies have shown that once patients or families fully understand end-of-life choices, they request fewer life-prolonging interventions. However, uncertainty about prognosis has been identified as a barrier to initiating DNH orders, with some HCPs making decisions about DNH orders without full understanding.
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Studies have found that 25% of nursing home patients received care that was inconsistent with their wishes
A person-centered approach to care in nursing homes has been found to improve resident satisfaction and quality of life. However, studies have found that 25% of nursing home patients received care that was inconsistent with their wishes. This is due to a variety of factors, including communication issues, staff attitudes, institutional processes, and a lack of human resources to ensure that person-centered care is provided.
Communication issues, for example, can lead to residents not feeling understood or respected, resulting in their wishes and needs going uncommunicated and, consequently, unmet. This can be further exacerbated by patronizing communication or "elderspeak" from staff, which is based on stereotypical expectations of residents' communication skills. Additionally, there may be a lack of shared decision-making, with residents and their families not being adequately involved in discussions about hospitalization.
To address these issues, communication training and person-centered interventions for caregivers have been suggested to improve caregiver-patient communication and encourage more openness from residents. Additionally, studies have recommended increasing the adoption of do-not-hospitalize (DNH) orders, which allow residents to forego further hospitalization and translate their preferences into medical orders. However, DNH orders are currently underutilized, with only 7% of nursing home residents having these orders in place.
Furthermore, there are concerns about the quality of care in nursing homes, with some homes providing inflated self-reported scores. Staffing shortages and high workloads can contribute to a lack of individualized care, and in some cases, residents may experience adverse events due to discontinuations in drug use or dose changes when transferred between facilities. Additionally, Medicare and Medicaid coverage for nursing home care have limitations, with Medicare only covering up to 100 days of care per benefit period and Medicaid requiring monthly deductibles in some cases.
To improve the quality of care and ensure that residents' wishes are respected, it is essential to address these staffing and financial challenges, implement accurate quality measurement systems, and prioritize person-centered care that takes into account the unique needs and preferences of each resident.
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Frequently asked questions
A DNH order is a medical order indicating that a nursing home resident or their responsible party does not wish to be hospitalized in the event of a medical emergency. It is a type of advance directive that translates a resident's preference for end-of-life care into a medical order.
DNH orders are rarely used, with only about 7% of nursing home residents having these orders in place. They are even less common among non-white residents and those in larger, for-profit nursing facilities. However, in a study of nursing facilities in Connecticut, DNH policies were in place for 62% of facilities, with the prevalence of DNH orders ranging from 12% to 23%.
DNH orders can help reduce potentially burdensome hospitalizations near the end of life, especially for residents with advanced illnesses or dementia. Hospitalizations can be distressing for patients and may not always improve their quality of life. DNH orders ensure that residents' wishes are respected and can also reduce unnecessary expenses associated with hospital transfers.
DNH orders are typically made by physicians based on the resident's current health status and prognosis. However, health care proxies (HCPs) often decide about DNH orders, especially for residents with advanced dementia. In some cases, residents or their family members may express their preferences for treatment, which should be respected by the nursing home staff.
