What DNH Orders Really Mean in Care Facilities

One paper presented at the AGS Meeting addressed the use of do-not-hospitalize (DNH) orders in nursing homes (NHs), as it has been suggested that more hospital transfers may be avoidable if they are more widely adopted. Researchers from Yale School of Medicine and the Connecticut area discussed how DNH orders are interpreted and used in real-world situations. 

The top 10% and bottom 10% of Connecticut skilled nursing facilities in terms of hospitalization rates (from 2008-2010) were identified using data from the Shaping Long Term Care in America Project, which created a database bringing together a variety of primary and secondary resources regarding the health and functional status of NH residents, characteristics of care facilitites, and data on state policies and the long-term care market.

Semistructured interviews with physicians, nurses, social workers, and administrators were conducted with select facilities until thematic saturation was reached, resulting in a total of 31 respondents from eight facilities. 

Grounded theory was used to analyzed the interview transcripts, and a multidisciplinary team developed a coding structure and identified themes.

Overall, interview responses showed that DNH orders were uncommon, and no significant differences were seen in the approaches of low- or high-hospitalizing facilities.     Participants who had used them commented that DNH orders did not, in fact, mean that a patient would not be hospitalized; rather, it was a warning or signal to staff to question whether to hospitalize the patient by default—this was often in the form of calling the family to ask them their preference for the specific situation. 

In patients with DNH orders, researchers saw that exceptions were often necessary, for example, if hospitalization was for patient comfort or a reason not related to the condition that had prompted the DNH order.

The presenters concluded that DNH orders did not necessarily prevent hospitalizations but instead prompted “in-the-moment” discussions about hospitalizations. Thus, increased prevalence DNH orders are not enough to reduce hospital transfers. The implications of this would be that providers may need to change the paradigm for planning for hospitalizations.

The presenters recommended that providers should instead focus on preparing patients and families ahead of time concerning best decisions about hospitalizations, noting that advance directives are only as good as the supporting and underlying patient-provider care discussions.
—Amanda Del Signore