Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective, longitudinal study

Background: No data-based evidence is available regarding the best time for nursing home nurses to obtain residents' signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries. Objectives: The purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents' mortality in Taiwan. Design: Retrospective, longitudinal design. Setting: Six nursing homes in Taiwan. Participants: Nursing home residents (N = 563). Methods: Data were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models. Results: The mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65 days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4 days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds = 2.57) and the number of transfers to hospital (odds = 1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10-3.98; p=0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99-3.59; p = 0.05). Conclusion: Early research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742 days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives. (C) 2016 Elsevier Ltd. All rights reserved.