End-of-Life Care in New York State Nursing Homes: Effective Communication and the Use of Advance Directives

Background Advance directives (ADs) provide information about personal preferences for life-saving or sustaining treatments, should one become incapacitated. AD discussions are particularly important in nursing homes (NHs) where 40% of all deaths in the US will occur by 2020. Yet, the prevalence of ADs varies widely across NHs. Anecdotal evidence suggests that staff's communication with residents/family members about end-of-life (EOL) treatment preferences may be associated with AD presence. Methods Primary and secondary data for CY2007 are used: individual characteristics (Minimum Data Set); facility characteristics (Online Survey, Certification, and Reporting file); facility-specific communication scores (survey of NY directors of nursing). The study sample includes 10,985 NH residents who died in CY2007 in 313 NYS facilities (representing a 52% survey response rate). To assess the contribution of individual, facility, and regional characteristics, independent variables are introduced into multivariate logistic regression models sequentially. Discussion and Conclusions Better communication score is a statistically significant (p<0.02) predictor of AD presence in all models. In an average facility, one standard deviation (0.61) increase in the communication score is associated with decedents having 12% higher odds of living will, 27% higher odds of do-not-resuscitate, 55% higher odds of do-not-hospitalize, and 24% higher odds of power of attorney. NH staff's ability to effectively communicate with residents and families about EOL treatments is significantly associated with residents' likelihood of having recorded ADs. Interventions to improve communication are the necessary first step for NH administrators to take to assure that EOL care is provided in accordance with residents' preferences.