Continuity of do-not resuscitate orders between hospital and nursing home settings.

OBJECTIVE: To determine the relationship between interinstitutional communication and continuity of advance directives from hospital to nursing home (NH) settings.

DESIGN: Retrospective chart review of discharges to hospital affiliated or community NHs.

SETTING: Teaching Veterans Affairs Hospital and affiliated and community nursing homes.

MEASUREMENTS: Demographic characteristics, medical diagnoses, presence of advance directives, and documentation that relates to the topic.

RESULTS: A total of 83 patients were discharged to either setting. Before discharge to a NH, the prevalence of chronic obstructive pulmonary disease and cancer was higher among those who had a DNR order. Overall, subsequent discussions about advance directives were equally common in NHs. Having a hospital discussion about advance directives or having a hospital DNR order were associated with a higher rate of advance directive discussions in NHs. Hospital DNR orders were continued for 93% and 41% of patients admitted to the hospital-affiliated NH compared with community NHs, respectively (P < .001). Specific communication of hospital DNR status to the receiving NH was associated with better continuity of DNR orders (49% vs 9%, P = .001). Factors that predicted continuity of DNR orders in logistic regression analysis correctly included hospital DNR status, communication of advance directives to the receiving NH, and NH advance directive discussions.

CONCLUSIONS: There is higher continuation rate of DNR orders between the hospital under study and its affiliated NH than to community NHs despite a similar frequency of confirmation discussions. Completing advance directives before patients are discharged to NHs, communication of advance directives to the receiving NH, and follow-up discussions at the NH may improve the continuity of advance directives between hospitals and nursing homes.