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 nur sing home population and to determine the factors that predict whether care is limited. Design: Retrospective chart review. Setting: All nur sing homes in Hennepin County, Minnesota that care for Medicaid patien ts. 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 i n that year. The residents were sampled disproportionately to allow ap proximately 400 individuals in each stratum. A total of 1405 charts (8 7%) was reviewed; the remainder had either been lost or destroyed. Mai n Outcome Measure: Orders limiting care (do not resuscitate, supportiv e care only, etc.), care that was less aggressive than care usually gi ven to a person of that age leg, not using antibiotics for a clear inf ection or not sending a resident to the hospital for an illness for wh ich someone would ''usually'' be sent to the hospital), determined imp licitly 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 19 88. The percentage of residents with 'do not resuscitate' orders (DNR) increased from 12% to 37% (P < 0.0001), and the use of other orders t o limit care (do not hospitalize, supportive care only, etc.) increase d from 12% to 17% (P < 0.05). The use of CPR did not change between th e 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 aggress ive care were similar except that age was also a significant predictor . Conclusions: The nursing home population received less aggressive ca re in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that reside nts with DNR orders had care limited beyond the withholding of CPR.