Do-not-Resuscitate/Do-not- Hospitalize Orders in Nursing Homes: Are they being done and do they make a Difference?

Transcription

1 Do-not-Resuscitate/Do-not- Hospitalize Orders in Nursing Homes: Are they being done and do they make a Difference? Peter Tanuseputro MHSc (CH&E), MD, CCFP, FRCPC (PHPM) Mathieu Chalifoux MSc

2 Acknowledgements 2 Team: Mathieu Chalifoux, Sarah Beach, Amy Hsu, Doug Manuel, etc. MOHLTC Health System Performance Research Network (HSPRN) Funding (i.e., Bank of Walter) Bruyère Research Institute (BRI) BRI Center for Learning, Research, and Innovation (CLRI) ICES

3 Background 3 Do not resuscitate (DNR) is a written legal order to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), in respect of the wishes of a patient in case their heart were to stop or they were to stop breathing (Wikipedia)

4 Background 4 DNH: 1) Absolute prohibition against sending someone to the hospital under any circumstances (often physician order) 2) Wish to avoid the hospital, with conditions.

5 Objectives 5 1) To describe the rates of Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) orders among residents admitted into long-term care homes (i.e., nursing homes). 2) Examine associations between patient characteristics and DNR/DNH rates 3) To assess the association of DNR and DNH on outcomes: survival, death in hospital, rates of hospitalization

6 Additional Objective 6 To describe the rates of additional Health System Quality Indicators for LTC across Local Health Integration Networks (LHINs): End-of-life Atlas Project Meaningful to add?

7 Methods 7 Design: Retrospective cohort study of all new admissions in 640 publicly funded long-term care facilities in Ontario, Canada. Data source: Health administrative databases at ICES Cohort: A population-level cohort of 49,390 incident admissions into long-term care facilities between January 1, 2010 and March 1, 2012 was observed Follow-up: admission to death, d/c, or study end

8 Methods 8 Main exposure variable: Presence of DNR and DNH at first assessment after LTC entry Data source: Resident Assessment Instrument (RAI) data, in Continuing Care Reporting System (CCRS) RAI Assessments unique features: Functional Status: ADL s, IADL s Cognitive Function Allied health services: PT, OT, PSW Longitudinal data CCRS linked to other ICES individual level

9 Methods 9 Outcome variables: 1) Mortality rate/median survival (RPDB) 2) Death in Hospital (CIHI DAD) 3) Rate of Hospital Visits & Admissions (Acute care, Complex Continuing Care, Rehab)

10 Additional Outcomes 10 1) Uncontrolled symptoms (CCRS) Shortness of breath in last 7 days or Moderate/severe pain in last 7 days 2) Quality of care (CCRS) Within last 90 days of assessments, any of: - Physical restraints used in the last 7 days - Ventilator use in the last 14 days - Fallen in the last 30 days

11 Additional Outcomes 11 3) Burdensome Transitions at end of life Any 1+ of: Transfer to another LTC facility in last 90 days (CCRS) 2+ Hospitalizations or 1+ Hospitalization for pneumonia, UTI, dehydration, sepsis in last 90d (CIHI DAD) ICU in the last 30 days (CIHI DAD) Any institution use (Acute care, ER, Complex Continuing Care, Rehab) in the last 3 days (CIHI DAD, NACRS, CCRS, NRS)

12 Results 12 What proportion of residents had a DNR on admission? a) 0-20% b) 20-40% c) 40-60% d) 60%+ Answer: 60.7%

13 Results 13 What proportion of residents had a DNH on admission? a) 0-20% b) 20-40% c) 40-60% d) 60%+ Answer: 14.8%

14 Results - % with DNR or DNH 14 80% 70% 60% 50% 40% 30% DNR DNH 20% 10% 0%

15 Results 15 Higher DNR associated with: Rural (70.7%) vs. urban (59.0%) Highest income quintile (62.6%) vs. lowest (58.5%) Widowed (65.9%) vs. Married (59.1%) vs. Divorced/Never married/separated (48.9%/48.0%/46.3%) Higher Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS) & Cognitive Performance Scale

16 CHESS % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% DNR DNH

17 Cognitive Performance Scale Very Severe Impairment 5 - Severe Impairment 4 - Moderate Severe Impairment 3 - Moderate Impairment 2 - Mild impairment 1 - Boderline Intact 0 - Intact 0% 10% 20% 30% 40% 50% 60% 70% 80% DNH DNR

18 Chronic Conditions % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% DNR DNH

19 Outcomes - Survival 19 No DNR DNR No DNH DNH Survival Times (n = 2 391) (n = 7,122) (n = 7,251) (n = 2,262) TOTAL Mean Median Q Q

20 Outcomes Rate of Hospital Visits & Admissions per 1,000 person years ,977 1,590 1,823 1, No DNR DNR No DNH DNH

21 Location of Death 21

22 Burdensome EOL

23 Uncontrolled Symptoms

24 Quality of Care

25 Rankings by LHINs 25 Ranking Burdensome Uncontrolled Quality of LHIN Transition symptoms care Average Erie St. Clair South West Waterloo Wellington Hamilton Niagara Haldimand Brant Central West Mississauga Halton Toronto Central Central Central East South East Champlain North Simcoe Muskoka North East North West

26 Conclusions 26 High rates of DNR, lower for DNH Both strongly associated with: Age, CHESS, CPS Curious relationships with: rurality, income, #chronic conditions Somewhat but not strongly related to survival

27 Conclusions 27 Some association with hospital visit rates and location of death Did the patient/family understand what DNH means? Was intention to avoid hospitalization, if possible, or to decline hospitalization for any reason? Considerable variability in additional outcomes across ON more work to unpack why s

28 Limitations/Next steps 28 Yet to run multivariable models DNR/DNH assessed on admission consider examining at future times Consider additional outcomes

29 29 QUESTIONS? Questions? Thank-you!