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Study to examine use, understanding of advance care preferences in nursing homes

November 17, 2016

INDIANAPOLIS -- Do nursing homes routinely record the treatment preferences of long-term residents when it comes to questions such as whether they want cardiopulmonary resuscitation if their heart and breathing stop?

Do residents fully understand the decisions they are asked to make?

The Retirement Research Foundation has awarded a $161,779 grant to Susan Hickman, an IU School of Nursing professor who is also co-director of the RESPECT -- Research in Palliative and End-of-life Communication and Training -- Center at Indiana University-Purdue University Indianapolis, to answer these questions.

Researchers will examine documentation for advance care planning in Indiana nursing homes and speak to residents and their family members about the advance care planning process. The findings will be applicable to nursing homes in other states as well as Indiana, Hickman said.

"This grant will allow us to assess whether nursing homes are accurately recording residents' current advance care planning preferences in their records and identify ways to help nursing homes improve their practice," Hickman said.

"That is really important because the likelihood that residents' treatment preferences will be honored dramatically increases when time is taken to discuss and record their preferences," she said.

The most common decision nursing home residents are asked to make is whether they want CPR attempted if their heart and breathing stop, Hickman said. Other decisions include whether to go to the hospital or have a feeding tube. Researchers expect to find that a majority of residents will have orders in the medical record about CPR, Hickman said.

"But it is also possible there have been no conversations about this order or that the conversations were very brief and didn't provide enough information for people to really understand the pros and cons of a resuscitation attempt."

For example, many residents might not know that the success rate for CPR among long-term nursing home residents is very low or that residents who survive will most likely spend time in an intensive care unit on a ventilator. Other risks include brain damage, broken ribs and punctured organs, according to Hickman.

Some residents are willing to risk these complications for a chance at a longer life, but others might not understand how low the odds are of success, she said.

Another important advance care decision that should be reflected in the nursing home medical record is whether a nursing home resident will be transferred to a hospital and under what circumstances, Hickman said. There is a growing body of evidence that hospitalizations carry significant risks for nursing home patients.

Hickman is already in the midst of a $2.2 million National Institutes of Health-funded study examining the use of an advance care planning tool called the Physician Orders for Scope of Treatment, or POST, in Indiana nursing homes.

Authorized by legislation adopted by the Indiana General Assembly in 2013, the Indiana POST is for patients near the end of life. Preferences for life-sustaining treatments, including resuscitation as well as medical interventions such as comfort care, hospitalization, intubation, mechanical ventilation, antibiotics and artificial nutrition, are documented as medical orders on the form.

The POST form transfers throughout the health care system, and the orders are valid in all settings, unlike most nursing home advance care planning orders.

The new grant from the Retirement Research Foundation will also allow the researchers to compare advance care planning practices in nursing homes that use POST with those in nursing homes that do not use POST.
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Indiana University

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