Comfort care is the stated goal of 96 percent of nursing home patients suffering from late-stage dementia, according to a study by the Beth Israel Deaconess Medical Center in Boston. However, hospitalization does not seem to work towards promoting that goal, as more than half of dementia patients die within 18 months of being transferred from a nursing home to a hospital.
Unbeknownst to many patients and their proxies, a “do not hospitalize” directive may be the best way to provide comfort to nursing home patients with dementia and allow nature to run its course. According to a study conducted by Dr. Michael Rothberg, vice chair for research in the Medicine Institute at the Cleveland Clinic, the health care proxies of the often incapacitated dementia patients are confused about what a “do not hospitalize” order is and how it works. The New York Times details the problem of the largely unknown, rarely understood directives.
What is a “do not hospitalize” directive?
The confusion regarding “do not hospitalize” orders may be the reason that, as recently as 2007, only 7.1 percent of patients in the national database of nursing home residents utilized such a directive. Rothberg’s study showed that, within the group of 16 health care proxies for patients with advanced dementia, most believed that a “do not hospitalize” order was the same as a request to withhold medical treatment completely. However, a “do not hospitalize” directive does not mean “do not treat.” The nursing home is still charged with making the best effort to treat the patient in the home, but “if nature takes its course, then that’s all right,” said Dr. John Culbertson an assistant professor at the Baylor College of Medicine.
How do these directives work?
Patients with dementia and their health care proxies generally have two types of “do not hospitalize” directives to choose from. One option is a prohibition against sending the patient to the hospital, no matter what the circumstances are. This directive is commonly utilized by older patients and their families who no longer feel that hospital treatment is necessary or worth the trouble. The second type of directive, a generally request to avoid the hospital, allows patients and their proxies to provide specifications as to the situations in which hospital treatment would be acceptable—such as to replace a catheter or to treat a broken bone. This type of directive could also be used to stipulate that each situation needs to be evaluated with the patient or his or her proxy to determine if hospital treatment is desired.
When is hospitalization the wrong choice?
The choice to skip hospitalization is often made in the cases of frail seniors with serious illnesses such as advanced dementia. In these cases, the benefits of hospitalization are unclear, but the setbacks frequently experienced (including delirium, poor nutrition, loss of mobility, disrupted sleep, and pain) are often dangerous. Patients with dementia are at greater risk for the inexplicable disorienting episodes known as hospital delirium, which is experienced by approximately one-third of patients over 70. Delirium can extend hospitalizations by slowing patients’ recovery and is known to contribute to death by causing weakening in patients, leading to complications such as pneumonia and blood clots.