Predictors of Site of Death of End-of-Life
Patients: The Importance of Specificity in Advance Directives.
Pekmezaris R, Breuer L, Zaballero A, Wolf-Klein G, Jadoon E,
D'Olimpio JT, Guzik H, Foley CJ, Weiner J, Chan S.
Parker Jewish Institute for Health Care and Rehabilitation, New
Hyde Park, New York.
Despite the compelling reasons for advance directives and their
endorsement by the public and medical professions, little is known
about their actual use and impact on site of death. This study was
conducted to examine the role of advance directives and other
"drivers" of hospitalization of the long-term care
end-of-life patient. The medical records of 100 deceased
consecutive nursing home residents, stratified by site of death
(skilled nursing facility or acute care hospital), were reviewed
by a team of geriatric researchers to obtain patient information
in the following domains: sociodemographic, advance directives,
transfer and death information, patient diagnoses at admission,
discharge, and other time intervals; medication usage and signs
and symptoms precipating death. Severity of illness was assessed
using the Cumulative Illness Rating Scale-G (CIRS-G). In testing
for differences between patients by site of death,
sociodemographic variables (gender, age, race, payer at discharge,
cognitive capacity) did not significantly differ between the two
groups of patients. Strong similarities between the groups were
also found in terms of severity of illness and medication usage.
Significantly higher proportions of patients dying in the nursing
home had specific advance directives (do not resuscitate, do not
intubate, do not artificially feed, do not hydrate, and do not
hospitalize), as opposed to those dying in the hospital. The
findings of this study demonstrate the impact of the explicit
advance directive on the decision to transfer the patient to the
acute care setting at the end of life.
PMID: 15000779 [PubMed - in process]