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J Am Med Dir Assoc. 2019 May 27. pii: S1525-8610(19)30329-9. doi: 10.1016/j.jamda.2019.03.034. [Epub ahead of print]

Adherence to "No Transfer to Hospital" Advance Directives Among Nursing Home Residents.

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Division of Geriatric Medicine, Queens University, Kingston, Ontario, Canada; Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Electronic address:
Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Division of Emergency Medical Services, Dalhousie University, Halifax, Nova Scotia, Canada.
Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.



Many older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, "no transfer to hospital" ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives.


We conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD).


ADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods.


ADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions.


The use of "no transfer to hospital" directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.


Advance directive; emergency services; falls; frailty; long-term care

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