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
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
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)
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.
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
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?
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
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 databases @ individual level
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)
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
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)
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%
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%
Results - % with DNR or DNH 14 80% 70% 60% 50% 40% 30% DNR DNH 20% 10% 0% 0-49 50-59 60-69 70-79 80-89 90 +
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
CHESS 16 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 1 2 3 4 5 DNR DNH
Cognitive Performance Scale 17 6 - 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
Chronic Conditions 18 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 0 1 2 3 4 5 6 7 8 9 10+ DNR DNH
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 771.9 698.2 726.6 685.0 716.7 Median 704 600 641 566.5 626 Q1 335 278 295 271 290 Q3 1153 1063 1108 1040 1091
Outcomes 20 2500 Rate of Hospital Visits & Admissions per 1,000 person years 2000 1500 1,977 1,590 1,823 1,244 1000 500 0 No DNR DNR No DNH DNH
Location of Death 21
Burdensome Transitions @ EOL 22 50 45 40 35 30 25 20 15 10 5 0
Uncontrolled Symptoms 23 60 50 40 30 20 10 0
Quality of Care 24 45 40 35 30 25 20 15 10 5 0
Rankings by LHINs 25 Ranking Burdensome Uncontrolled Quality of LHIN Transition symptoms care Average Erie St. Clair 9 10 6 8.3 South West 6 7 10 7.7 Waterloo Wellington 1 5 7 4.3 Hamilton Niagara Haldimand Brant 3 9 11 7.7 Central West 13 4 3 6.7 Mississauga Halton 10 1 4 5.0 Toronto Central 14 3 1 6.0 Central 11 2 2 5.0 Central East 12 8 5 8.3 South East 2 14 14 10.0 Champlain 7 6 12 8.3 North Simcoe Muskoka 4 12 8 8.0 North East 8 11 9 9.3 North West 5 13 13 10.3
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
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
Limitations/Next steps 28 Yet to run multivariable models DNR/DNH assessed on admission consider examining at future times Consider additional outcomes
29 QUESTIONS? Questions? Thank-you! PTANUSEPUTRO@OHRI.CA