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J Am Geriatr Soc. 2004 Jan;52(1):51-8.

Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections.

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Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, Columbia, Missouri 65212, USA.



To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).


Prospective cohort.


Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.


NH residents with a LRI (n=1031).


Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.


Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97).


DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.

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