Stability of DNR and CPR preferences among LTC nursing home residents

High quality care for long-term nursing home (NH) residents should include discussions and follow-up on residents' end-of-life care wishes. Recent changes to the MDS exclude this information, making the provision of high quality end-of-life care less likely. We examined the stability of cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders to offer guidance for policy and care practice.

We studied changes in CPR/DNR status of 118,247 long-term residents in all NHs nationally admitted in 2003, following them for 5 years. We estimated competing risk models to identify covariates predicting changes from CPR to DNR and vice-versa. Covariates included patient-level variables, facility characteristics, and states fixed effects. Analysis was stratified by residents' dementia status.

About half the cohort chose DNR at admission and did not change its status. Of those entering with CPR status, 40% changed to DNR. Compared with those who chose DNR on admission, those who chose CPR were more likely to be male, younger, Black or Hispanic, and had less education. They tended to have fewer comorbidities, depressive symptoms, aggressive symptoms, and were less likely to have dementia. The most important factors influencing change from CPR to DNR were hospitalizations and nursing home transfers. Nursing home characteristics also influenced the likelihood of changing from CPR to DNR. Dementia had only minor impact on the results. These findings suggest that CMS should consider reinstating information about DNR in the MDS to ensure that changes in resident preferences are known and are acted upon at the end of life.