CHANGES IN ADVANCE CARE PLANNING IN NURSING-HOMES BEFORE AND AFTER THE PATIENT SELF-DETERMINATION ACT - REPORT OF A 10-STATE SURVEY

OBJECTIVE: The Patient Self-Determination net (PSDA) implemented in 19 91 has focused national attention on the right of patients to be invol ved in decision-making and on the use of written advance directives. W e report changes in advance care planning with the PSDA and other hist orical events in nursing homes in 10 states. DESIGN: Pre- and Post-obs ervational cohort study PATIENTS: Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure repre sentation of urban and rural facilities in each state. In 1990. 2175 p atients were sampled, and 2088 different patients from the same facili ties were sampled in 1993. Six-month follow-up was obtained at both ti me periods. MAIN OUTCOME MEASURES: Advance care planning was defined a s the documentation in the medical record of a living will, a durable power of attorney, a ''Do Not Resuscitate'' (DNR) order, a ''Do Not Ho spitalize'' (DNH) order, or an order to forgo artificial nutrition or hospitalization. RESULTS: The rate of chart documentation of living wi lls increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders incre ased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% acr oss the 10 states. With the exception of Oregon, where 69.2% of patien ts already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990. CONCLUSION: Wit h the implementation of the PSDA, there was modest increase in documen tation of living wills, but DNH and orders to forgo artificial hydrati on and nutrition remained the same. There was a substantial increase i n DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increa sed debate about the appropriateness of CPR for nursing home residents . This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic varia tion.