CHANGES IN ORDERS LIMITING CARE AND THE USE OF LESS AGGRESSIVE CARE IN A NURSING-HOME POPULATION

Objective: To examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited. Design: Retrospective chart review. Setting: All nursing homes in Hennepin County, Minnesota that care for Medicaid patients. Patients: A random sample of 1605 residents of Hennepin County, MN nursing homes from 1984 and 1988 who were also Medicaid beneficiaries. The sample was stratified by year and by whether the resident died in that year. The residents were sampled disproportionately to allow approximately 400 individuals in each stratum. A total of 1405 charts (87%) was reviewed; the remainder had either been lost or destroyed. Main Outcome Measure: Orders limiting care (do not resuscitate, supportive care only, etc.), care that was less aggressive than care usually given to a person of that age leg, not using antibiotics for a clear infection or not sending a resident to the hospital for an illness for which someone would ''usually'' be sent to the hospital), determined implicitly through chart review. Results: The demographic characteristics of the nursing home population did not change between 1984 and 1988, but the population had significantly greater severity of illness in 1988. The percentage of residents with 'do not resuscitate' orders (DNR) increased from 12% to 37% (P < 0.0001), and the use of other orders to limit care (do not hospitalize, supportive care only, etc.) increased from 12% to 17% (P < 0.05). The use of CPR did not change between the two years but the percentage of residents who were found to receive less aggressive care through implicit chart review increased from 31% to 40% (P < 0.01). The year the resident was in the nursing home, the severity of illness, functional status, and dementia were significant predictors of DNR status. Factors that predict receipt of less aggressive care were similar except that age was also a significant predictor. Conclusions: The nursing home population received less aggressive care in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that residents with DNR orders had care limited beyond the withholding of CPR.