Sunday, November 24, 2013
"Do Not Hospitalize" is the latest initiative in advance care directives, driven by emerging recognition of the variety of ways that individuals may not be well served by extra-ordinary care measures, requiring specific directions. The concept may require lawyers drafting traditional living wills to think more broadly. Further, the concept highlights the importance of families working directly with physicians who are sensitive to the larger dynamic.
I have to say this one hits home in my own family. My father, after physical health problems combined with larger frailty, declared at age 86, "I would rather die on the steps of the hospital" than spend another night there. That has been hard, at times, for my family to accept.
The New York Times in Judith Graham's "A Misunderstood Directive," provides a back story for the use of DNH orders. Dr. Michael Rothberg describes what occurred after his father-in-law, with severe dementia, was transferred from a care facility to a hospital for evaluation, a move that triggered even greater disorientation and reaction by the man, leading to restraints and medication. The theory of DNH is to provide a reasoned basis not to see hospitalization as the only option for patients, especially those with dementia:
"After another difficult hospitalization, this time for pneumonia, the family decided they didn’t want this vulnerable, distressed relative transferred from the nursing home again if he took ill. They asked that a “do not hospitalize” order be communicated to staff and placed in his medical record. Several months later, the patient stopped eating and drinking and passed away."
Dr. Rothberg and colleagues in Pennsylvania and Massachusetts have collaborated on a paper to describe and evaluate Do Not Hospitalize directives entered into by authorized agents (health care proxies or HCPs) for individuals with advanced dementia. They conclude:
"The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes."