• Dana B Mukamel, Heather Ladd, and Helena Temkin-Greener.
• Department of Medicine, Health Policy Research Institute, University of California, Irvine, CA 92697-5800, USA. dmukamel@uci.edu
• Med Care. 2013 Aug 1;51(8):666-72.

BackgroundHigh-quality care for long-term nursing home residents should include discussions and follow-up on patients' end-of-life care wishes. Yet, recent changes to the Minimum Data Set data collection exclude this information from routine assessment of patients mandated by the Centers for Medicare & Medicaid Services, 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 to policy and care practice developments.MethodsWe examined changes in DNR status of a national long-term care nursing home cohort, following them for 5 years after admission. A competing risk model was estimated to identify covariates predicting changes from CPR to DNR status and vice versa.ResultsAbout half the cohort chose DNR at admission and did not change its status. Of those who entered with CPR status, 40% changed to DNR. The most important factors influencing change were hospitalizations and nursing home transfers, followed by race and ethnicity with black race (relative to white) in particular having the largest effect on change. Other individual and nursing home characteristics influenced the likelihood of changing from CPR to DNR as well.ConclusionsLong-term nursing home patients who enter with full-code CPR have a high probability of changing their status to DNR during their stay. High-quality care should offer them the opportunity to revisit their choice periodically, documenting changes in end-of-life choices when they occur, thus ensuring that care will match patients' wishes. As the Minimum Data Set plays a prominent role in patients' care, Centers for Medicare & Medicaid Services should consider reinstating information about advance directive in it.

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