Monday, 18 November 2019: 4:05 PM
Background: Successful advance care planning (ACP) is knowing and respecting patient and family choices about end-of-life (EOL) care. An important aspect of care is empowering patients to die where they prefer. For most, it is to die at home (Gomes, Calanzani, Gysels, Hall, & Higginson, 2013). Nevertheless, there is evidence from studies globally demonstrating that hospitalization and subsequently non-beneficial treatments (NBTs) are common at EOL (Cardona-Morrell, Kim, Turner, Anstey, Mitchell, & Hillman (2016). Dying at home is often not an option in SNF’s where older persons often face frailty, co-morbidities, high functional needs and polypharmacy. However, dying peacefully can be and should be an option for SNF residents, but transfer to a hospital can quickly lead to a spiral of unwanted treatment and secondary problems that lead to hospital death about 20% of the time (Temkin-Greener, Zheng, Xing, & Mukamel, 2013). Nurses are on the front lines as residents decline in SNF and are in a unique position to advocate for patients wishes for “do not hospitalize” (DNH) orders as part of ACP (Lasater, Sloane, McHugh, & Aiken, 2018; Ludwick, Baughman, Dajoura, & Kropp, 2018). DNH orders are resident specific and give guidance when a resident’s health declines about their wishes about EOL care (Cohen, Knobf & Fried, 2017). Research has shown these orders can decrease overall rates of hospital and emergency room transfers (Nakashima, Young, Wan-Hsiang, 2017) and thus play an important role in ACP.
Purpose: This study’s aim was to explore the impact of DNH policy knowledge, education, and advocacy and the SNF overall star ratings on the practice of using DNH orders by nurses (registered and licensed; RN, LPN) and social workers (SWs) employed in SNFs.
Methods: This multisite secondary analysis was part of a larger funded project that examined the impact of race and disease trajectory on professional judgments about ACP. Using cross-sectional survey data from the larger study we analyzed the responses of RNs, LPNs and SWs (N=354) from 29 urban SNFs in one Midwestern state about DNH practices. Data were also collected from the nursing directors at each SNF about their written facility DNH policies and from the Medicare Nursing Home Compare public website on the overall star of the SNF.
Analysis: Descriptive statistics were used to describe the respondents and their DNH practices. Mixed models regression was used to predict the frequency of ACP discussions about DNH orders within SNFs while adjusting for random effects.
Results: Most respondents were either an RN (39%) or LPN (51%), female (91%), white (76%) between the ages of 30 and 60 (76%) and worked at their facility less than 5 years (52%). The majority (81%) reported that their facility had a DNH policy; nursing directors reported 69% of their facilities had a DNH policy. When respondent and director answers were individually compared, 38% of respondents did not correctly match whether their facility had a policy. DNH education was measured on a 1 to 5 scale (1 = no education; 5 = a lot of education); the mean response was 3.4, but 13% reported no DNH education. A majority (83%) reported that their facility had a strong leader or advocate for ACP use. The overall star rating of each SNF ranged from 1(low) to 5 (high) and included 3 measures: health inspection, staffing, and quality. The
mean star rating was 2.6; only 4 SNFs had a five-star rating When asked how often DNH orders were practiced at work (dependent variable) on a 1 (rarely) to 5 (almost always) scale the mean frequency was 3.8.
Mixed models showed that having a DNH written policy (b=1.09, p<0.001), education on DNH orders (b=0.33, p<0.001), and having an ACP advocate in the facility (b=0. 60, p<0.001), were all strong predictors of a high frequency of DNH discussions with residents and their families. The star ratings were not predictive of DNH practice, nor was the licensure of the provider.
Conclusions/Implications: This multi-site study showed the significance of DNH written policies, education, and ACP advocacy in predicting the frequency of DNH practice. Data about policies reflect a need for ongoing policy review of ACP and its components. This data also raises questions about the understanding of not only written overt policy but the covert understandings of policy and the need for ongoing staff policy education. The impact of a strong advocate for DNH policy may not be surprising given that advocates are frequently used in nursing initiatives, but further empirical study is warranted to better understand this role. As skilled long-term care grows globally and technology advances, advocating for EOL choices will need ongoing vigilance and research. This study, limited to self-report data from one region in one state with limited generalizability, shows the important groundwork that still needs to be done among researchers, leaders and practitioners in SNFs as they are tasked with managing the complex and changing pieces of ACP, specifically DNH orders.
Purpose: This study’s aim was to explore the impact of DNH policy knowledge, education, and advocacy and the SNF overall star ratings on the practice of using DNH orders by nurses (registered and licensed; RN, LPN) and social workers (SWs) employed in SNFs.
Methods: This multisite secondary analysis was part of a larger funded project that examined the impact of race and disease trajectory on professional judgments about ACP. Using cross-sectional survey data from the larger study we analyzed the responses of RNs, LPNs and SWs (N=354) from 29 urban SNFs in one Midwestern state about DNH practices. Data were also collected from the nursing directors at each SNF about their written facility DNH policies and from the Medicare Nursing Home Compare public website on the overall star of the SNF.
Analysis: Descriptive statistics were used to describe the respondents and their DNH practices. Mixed models regression was used to predict the frequency of ACP discussions about DNH orders within SNFs while adjusting for random effects.
Results: Most respondents were either an RN (39%) or LPN (51%), female (91%), white (76%) between the ages of 30 and 60 (76%) and worked at their facility less than 5 years (52%). The majority (81%) reported that their facility had a DNH policy; nursing directors reported 69% of their facilities had a DNH policy. When respondent and director answers were individually compared, 38% of respondents did not correctly match whether their facility had a policy. DNH education was measured on a 1 to 5 scale (1 = no education; 5 = a lot of education); the mean response was 3.4, but 13% reported no DNH education. A majority (83%) reported that their facility had a strong leader or advocate for ACP use. The overall star rating of each SNF ranged from 1(low) to 5 (high) and included 3 measures: health inspection, staffing, and quality. The
mean star rating was 2.6; only 4 SNFs had a five-star rating When asked how often DNH orders were practiced at work (dependent variable) on a 1 (rarely) to 5 (almost always) scale the mean frequency was 3.8.
Mixed models showed that having a DNH written policy (b=1.09, p<0.001), education on DNH orders (b=0.33, p<0.001), and having an ACP advocate in the facility (b=0. 60, p<0.001), were all strong predictors of a high frequency of DNH discussions with residents and their families. The star ratings were not predictive of DNH practice, nor was the licensure of the provider.
Conclusions/Implications: This multi-site study showed the significance of DNH written policies, education, and ACP advocacy in predicting the frequency of DNH practice. Data about policies reflect a need for ongoing policy review of ACP and its components. This data also raises questions about the understanding of not only written overt policy but the covert understandings of policy and the need for ongoing staff policy education. The impact of a strong advocate for DNH policy may not be surprising given that advocates are frequently used in nursing initiatives, but further empirical study is warranted to better understand this role. As skilled long-term care grows globally and technology advances, advocating for EOL choices will need ongoing vigilance and research. This study, limited to self-report data from one region in one state with limited generalizability, shows the important groundwork that still needs to be done among researchers, leaders and practitioners in SNFs as they are tasked with managing the complex and changing pieces of ACP, specifically DNH orders.