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  • Title: Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective, longitudinal study.
    Author: Tsai HH, Tsai YF, Liu CY.
    Journal: Int J Nurs Stud; 2017 Mar; 68():9-15. PubMed ID: 28033524.
    Abstract:
    BACKGROUND: No data-based evidence is available regarding the best time for nursing home nurses to obtain residents' signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries. OBJECTIVES: The purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not-resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents' mortality in Taiwan. DESIGN: Retrospective, longitudinal design. SETTING: Six nursing homes in Taiwan. PARTICIPANTS: Nursing home residents (N=563). METHODS: Data were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models. RESULTS: The mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds=2.57) and the number of transfers to hospital (odds=1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10-3.98; p=0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99-3.59; p=0.05). CONCLUSION: Early research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives.
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