SURROGATE AND PHYSICIAN UNDERSTANDING OF PATIENTS PREFERENCES FOR LIVING PERMANENTLY IN A NURSING-HOME

OBJECTIVE: To evaluate patients' willingness to live permanently in a nursing home and surrogate and physician understanding of that prefere nce. DESIGN: Evaluation of cross-sectional interview data from a cohor t study. SETTING: Five academic medical centers. PARTICIPANTS: Serious ly ill hospitalized adults enrolled in the Study to Understand Prognos es and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEA SUREMENTS: Patients' willingness to live permanently in a nursing home was measured on a 5-point scale ranging from ''very willing'' to ''ra ther die.'' Ordinal logistic regression was used to identify patient d emographic and clinical characteristics associated with this preferenc e. Surrogate and physician perceptions of patient preferences were com pared with patients' responses, and factors associated independently w ith surrogate and physician understanding of patient preference were i dentified. RESULTS: Of 9105 patients, 3262 (36%) provided responses to the study question: 7% were ''very willing'' to live permanently in a nursing home, 19% ''somewhat willing,'' 11% ''somewhat unwilling,'' 2 6% ''very unwilling,'' and 30% would ''rather die.'' Older age was ass ociated independently with less willingness to live permanently in a n ursing home (odds ratio [OR]=.90 per decade; 95% confidence interval [ CI]: 0.85, 0.96). Patients with more education (OR = 1.03 per year; 95 % CI:1.00,1.05) and more disabilities (OR = 1.05 per disability; 95% C I:1.01,1.09), and black patients (OR = 1.46 compared with white patien ts; 95% CI:1.20,1.76) were more willing to live in a nursing home. Sur rogates understood 61% of patients' nursing home preferences but ident ified only 35% of patients who were willing to live permanently in a n ursing home. Physicians identified 18% of patients willing to live per manently in a nursing home. CONCLUSION: Patient attitudes about living permanently in a nursing home can be elicited, cannot be reliably pre dicted from demographic and clinical variables, and are frequently mis understood by surrogates and physicians. Elicitation of patient prefer ences regarding permanent nursing home placement should be explored be fore patients become unable to participate in decision making in order to enhance the concordance of patient preference with the way they sp end the end of their lives.