Carrefour de l'innovation et de l'évaluation en santé, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.
School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.
BMC Geriatr. 2022 Jan 3;22(1):22. doi: 10.1186/s12877-021-02699-5.
Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes.
In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015.
We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65-0.69), 0.63 (0.61-0.65), and 0.47 (0.43-0.52) for residents with low, moderate and high health instability, respectively.
Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.
长期护理院（LTCH）的居民在生命末期经常经历不必要和无益的住院和干预。预先护理指令旨在确保临终护理尊重居民的需求和意愿。
在这项回顾性队列研究中，我们使用多状态模型来检查与安大略省、艾伯塔省和不列颠哥伦比亚省加拿大 LTCH 入院居民的 DNR 和 DNH 指令相关的健康轨迹。我们调整了基线与虚弱相关的健康不稳定。我们考虑了三种可能的终末状态：健康状况变化、住院或死亡。对于测量，我们使用了标准化的 RAI-MDS 2.0 LTCH 评估，并与 2010 年至 2015 年的医院记录相关联。
我们报告了 123,003 名 LTCH 居民。DNR 和 DNH 指令的患病率分别为 71%和 26%。这两个指令都与向健康不稳定和死亡状态过渡的几率增加以及住院几率降低相关。尽管存在 DNH 指令，但住院的几率降低了，但并未消除，低、中、高健康不稳定居民的几率分别为 0.67（95%置信区间 0.65-0.69）、0.63（0.61-0.65）和 0.47（0.43-0.52）。
即使 DNR 和 DNH 订单都与严重的健康结果相关，但 DNH 指令并未得到广泛使用，并且经常被推翻。我们建议重新评估推荐 DNH 指令的政策，更加注重预先护理计划，更好地反映居民的价值观和愿望。
