Are nursing home patients with serious mental illness less likely to have advance care plans than other nursing home patients?

Nursing home patients with serious mental illness (SMI) tend to command a high level of medical and end-of-life services, in addition to their apparent need for psychiatric care. Advance care plans document a person's wishes regarding treatment choices or identify a proxy for healthcare decisions should the individual becomes terminally ill. Nursing home staff may assume that persons with SMI ipso facto lose decisional capacity to participate in advance care planning; it is, however, a common misconception proved to be stigmatizing. This study analyzed data of the 2004 National Nursing Home Survey of SMI (n=1769) and non-SMI (n=13507) residents and tested whether those with SMI were less likely to have (1) living wills, (2) do not resuscitate order, (3) do not hospitalize order, and (4) order of restricting feeding tube, medication or other treatments. We found that the overall rate of any of the 4 advance care plans were 57% and 68% for SMI and non-SMI residents, respectively. In a multivariate logistic analysis adjusting for patient and facility characteristics, as well as survey procedures, SMI was associated with a 24% reduced odds of having any advance directives (Odds Ratio=0.76, 95% Confidence Interval 0.66-0.87, p=0.000). Similar results were found for each individual advance care document. Our findings suggest disparity in end-of-life care among nursing home patients with SMI. Future research is needed to help understand both patient factors (eg, inappropriate behaviors, impaired communication skills, and disrupted family support) and provider factors (eg, training, experience, and attitude) that underlie these findings.