Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

Abstract

Background: Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital. Aim: Examine the relationship between dementia, DNR timing, and end-of-life care intensity. Design: Observational cohort study. Setting/Participants: Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017. Results: Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission. Conclusions: Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

Associations between dementia diagnosis and end‐of‐life care utilization

“…An analysis of pre‐2008 Health and Retirement Study data indicated PLWDs were less likely to undergo intensive procedures including mechanical ventilation, intubation, hemodialysis, and CPR at the EOL 3 . Moreover, previous studies are limited in that they only examined selected measures of EOL care intensity, 3,10,12,13 focused on specialized patient populations (e.g., individuals with cancer), 13 or used small samples from limited geographic areas or particular care settings (e.g., nursing homes) 2,4,10 . Finally, dying PLWD also increasingly experience care that promotes their quality of life, including hospice care and home death, 1 These shifts underscore the need to better understand both intensive and comfort‐focused EOL care in this population.…”

“…3 Moreover, previous studies are limited in that they only examined selected measures of EOL care intensity, 3,10,12,13 focused on specialized patient populations (e.g., individuals with cancer), 13 or used small samples from limited geographic areas or particular care settings (e.g., nursing homes). 2,4,10 Finally, dying PLWD also increasingly experience care that promotes their quality of life, including hospice care and home death, 1 These shifts underscore the need to better understand both intensive and comfort-focused EOL care in this population. Patients often experience both intensive and quality of life-promoting care near the EOL, as evidenced by trends in increased care intensity, hospice use, and days at home.…”

“…1 However, the relationship between dementia and end-of-life (EOL) care intensity is not well-established, varying by the EOL care measure studied. [2][3][4][5][6][7][8][9] Care "intensity" can be measured in several ways including the principal domains of greater intensity represented by measures of medical care utilization intended to prolong life. 2,3,10 However, uncertainty in the relationship between dementia and EOL care intensity is evident in studies dating to the 2000's.…”

“…Dementia is a leading and growing cause of death for individuals over age 65 1 . However, the relationship between dementia and end‐of‐life (EOL) care intensity is not well‐established, varying by the EOL care measure studied 2–9 . Care “intensity” can be measured in several ways including the principal domains of greater intensity represented by measures of medical care utilization intended to prolong life 2,3,10 .…”

“…[2][3][4][5][6][7][8][9] Care "intensity" can be measured in several ways including the principal domains of greater intensity represented by measures of medical care utilization intended to prolong life. 2,3,10 However, uncertainty in the relationship between dementia and EOL care intensity is evident in studies dating to the 2000's. For example, 40% of primarily non-Hispanic White persons living with dementia (PLWD) in a sample of Massachusetts nursing homes received intensive EOL services including hospitalization and artificial nutrition.…”