Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the medicare benefit

OBJECTIVES: To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. DESIGN: Retrospective cohort study. SETTING: Nursing homes in the United States. PARTICIPANTS: Medicare admissions to SNFs in 2001 (n = 1,962,742). MEASUREMENTS: Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. RESULTS: Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR) = 0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR = 0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. CONCLUSION: Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.